Understanding pharmacology in nursing practice

123

Pauline Hood

Ehsan Khan

Editors

Understanding

Pharmacology in

Nursing Practice

Understanding Pharmacology

in Nursing Practice

Pauline Hood • Ehsan Khan

Editors

Understanding

Pharmacology

in Nursing Practice

Editors

Pauline Hood

(Retired) Florence Nightingale Faculty of

Nursing, Midwifery & Palliative Care

King’s College London

London

UK

Ehsan Khan

Florence Nightingale Faculty of

Nursing, Midwifery & Palliative Care

King’s College London

London

UK

ISBN 978-3-030-32003-4 ISBN 978-3-030-32004-1 (eBook)

https://doi.org/10.1007/978-3-030-32004-1

© Springer Nature Switzerland AG 2020

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v

Preface

‘‘Were there none who were discontented with what they have, the world would never reach

anything better.’’

Florence Nightingale (1852: 29)

Contemporary health care practice is informed and shaped by the abundance of

dynamic advances in medical science. Therapeutic pharmacology is an aspect of

such development and a central feature of clinical practice. It is crucial therefore

that to practise responsibly, nurses and other health care practitioners have a sound

understanding of how drugs cause action and effect.

While it is envisaged that this book will be useful for a range of health care prac￾titioners, the emphasis is on the role of the nurse and the use of prescribed medica￾tion in practice with a focus on the adult service user.

Registered nurses practise in a diverse range of health care settings, where pre￾scribed medication is invariably a key component of planned care for the service

user. Entirely appropriately, there is an emphasis on safe administration of pre￾scribed medication in practice, i.e. the five rights ‘right patient, right drug, right

dose, right route, and right time’ (Eisenhauer et al. 2007). Additionally, the nurse

must ensure that they educate the service user about the drug regimen, not just from

a ‘why’, ‘what’, ‘how’, and ‘when’ perspective, but by also discussing what impact

the drug(s) may/will have and by reiterating the therapeutic goal. Monitoring,

reporting, and documenting a service user’s pharmacological response to drug ther￾apy in terms of treatment outcomes is also a significant aspect of the nurse’s role

together with being aware of possible adverse reactions of administered

medication.

To achieve the quality of care required and to uphold regulatory standards of

proficiency (NMC 2018) and other guidance (RPS 2013), it requires the practitioner

to have both a panoptic and a detailed knowledge of pharmacology juxtaposed with

an understanding of the legal and ethical aspects of the nurse's role and drug

therapy.

This book has been composed by health care professionals who are dedicated to

promoting knowledgeable, safe care. Our goal is to inform, inspire, and advance

health care; we envisage the structure and content of the book will help to achieve this.

London, UK Pauline Hood

London, UK Ehsan Khan

vi

References

Eisenhauer LA, Hurley AC, Dolan N (2007) Nurses’ reported thinking during medi￾cation administration. J Nurs Scholarship 39(1):82–87

Nightingale F (1852) Cassandra. In: Stark M, Macdonald C (1979) Florence

Nightingale’s, angry outcry against the forced idleness of Victorian women,

Cassandra. The City University New York. The Feminist Press, New York

Nursing and Midwifery Council (2018) Future nurse: standards of proficiency for

registered nurses. NMC, London

Royal Pharmaceutical Society (2013) Medicines optimisation: helping patients to

make the most of medicines. Royal Pharmaceutical Society, London

Preface

vii

Contents

Part I Legal and Ethical Issues

1 Legal and Ethical Issues Associated with Medication . . . . . . . . . . . . . . 3

Sherri Ogston-Tuck

Part II Principles of Pharmacology

2 Pharmacokinetics and Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . 27

Ehsan Khan

3 Drug Formulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Ali A. Dahab

4 Adverse Drug Reactions and Drug Interactions . . . . . . . . . . . . . . . . . . 89

Nicola Husain

Part III Systemic Pharmacology

5 Pharmacology of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Sheila Turner

6 Antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Edward Purssell

7 Medications Used for the Cardiovascular System . . . . . . . . . . . . . . . . . 167

Joan Adams and Ehsan Khan

8 Medications Used for the Renal System . . . . . . . . . . . . . . . . . . . . . . . . . 219

Roseline Elsie Agyekum

9 Medications Used for Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . 255

Haya Abu Ghazaleh and Ehsan Khan

10 Medications Used for the Respiratory System . . . . . . . . . . . . . . . . . . . . 283

Shelley Peacock

11 Medications Used for the Gastrointestinal System . . . . . . . . . . . . . . . . 319

Ehsan Khan

viii

12 Medications Used for the Central Nervous System . . . . . . . . . . . . . . . . 345

Ehsan Khan

13 Medications Used for Mental Health Illness. . . . . . . . . . . . . . . . . . . . . . 367

Ehsan Khan

14 Medications Used for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Mary Anne Lagmay Tanay

Contents

Part I

Legal and Ethical Issues

© Springer Nature Switzerland AG 2020 3

P. Hood, E. Khan (eds.), Understanding Pharmacology in Nursing Practice,

https://doi.org/10.1007/978-3-030-32004-1_1

S. Ogston-Tuck (*)

Three Counties School of Nursing and Midwifery, College of Health, Life and Environmental

Sciences, St John’s Campus, University of Worcester, Worcester, UK

e-mail: [email protected]

1 Legal and Ethical Issues Associated

with Medication

Sherri Ogston-Tuck

Learning Outcomes

At the end of this chapter, you will be able to:

• Have an understanding of the professional role of the nurse in medicine

management

• Recognise safeguards in clinical practice such as legislation, policy and profes￾sional regulation

• Have an understanding of the legal concepts and principles associated with med￾icine management and the process of consent to treatment

• Have an understanding of possible ethical-legal-professional dilemmas in clini￾cal practice

1.1 Introduction

This chapter considers the legal, professional and ethical concepts integral to nurs￾ing practice as applied to medicine management.

Medicines are a fundamental tool to prevent and manage a diverse range of dif￾ferent conditions and disease. A thorough understanding of the legal, professional

and ethical issues associated with medicine management is therefore an essential

component of nursing care (Ogston-Tuck 2011).

The law and nursing practice is influenced by research and technological advances

juxtaposed with a growing awareness and expectation from the service user and the

public of their rights and privileges about healthcare. As such, the possibility of litiga￾tion in healthcare compels nurses to have a focused understanding of the legal

4

principles, professional implications and the ethical dilemmas that arise and challenge

practice when managing and administering medicines to patients. Questioning and

reflecting on practice is an essential means of understanding the professional-ethical￾legal issues in contemporary healthcare practice; questioning what the ‘right thing to

do’ is and understanding the concept of what is termed a ‘legal duty of care’. These

questions need to be explored, alongside accountability, safe practice and consent to

treatment. These aspects of the discussion are related to pharmacology and clinical

practice and will therefore be explored using practice scenarios and focused activities.

There should be no doubt that the nurses’ role is fundamental to the safe practice

of medicine management, which encapsulates both professional responsibility and

legal liability.

1.2 Professionalism and Accountability

Professional behaviour and accountability stem from standards of care and encom￾pass what is perceived as ‘professionalism’. How a practitioner respects an indi￾vidual and their autonomy must reflect professional standards; this is a fundamental

aspect of the context of a healthcare professional. For nurses, this not only requires

an understanding of their role but extends to their underlying knowledge and skill.

In relation to medicine management, this lends itself to an understanding of the

values and ethics of the profession. What is expected of nurses as healthcare profes￾sionals, when caring for patients while appreciating their particular circumstances,

requires nurses to be familiar with the concept of ethics and professionalism.

Professionals establish their practice through professional regulation.

Safeguarding the public is achieved through statutory regulation, for any healthcare

professional. The role of the NMC is to set the standards in the Code—these are the

standards that patients and members of the public expect from health professionals

(NMC 2018:3). These are the standards of conduct and behaviour which all regis￾trants have a commitment to upholding. The Code provides a clear, consistent and

positive message to patients, service users and colleagues about what they can

expect of those who provide nursing or midwifery care (NMC 2018:4) putting the

interests of patients and service users first. The purpose of the NMC is to make

certain that registrants meet the requirements and standards set by the Council

through education and training and to demonstrate and maintain these standards in

practice. Clinical practice must therefore be safe and legal. The NMC can take

action when registered nurses or midwives fail to uphold the Code—and in serious

cases, this can include removing them from the register (NMC 2018).

The Code is structured around four themes: prioritise people; practice effec￾tively; preserve safety; and promote professionalism and trust. While nurses and

midwives can interpret the values and principles set out in the Code, they are not

negotiable or discretionary (NMC 2018:3).

The Code should be seen as a way of reinforcing professionalism (NMC 2018:5).

It contains a series of statements that when taken together signify what good nursing

is—putting the interests of patients and service users first (NMC 2018:5).

S. Ogston-Tuck

5

The role of the nurse demands that they are consistently practising in a way that

is safe and professional. Therefore, as a professional, the nurse must always act law￾fully in both their professional practice and personal life. The professional register

is open to public scrutiny, wherein the public are able to access information about

registrants. This includes practice standards, fitness for practice, adherence to pro￾fessional guidelines and professional conduct. It should be clear then that being a

professional is about the way in which a person acts as it relates to one’s morals and

virtues, issues of morality, ethics and law.

1.3 Accountability

A professional role and duty of care encompasses professional accountability. This

means nurses are accountable for what they do and for what they do not do and are

personally accountable for their practice (Ogston-Tuck 2011). A nurses’ duty of

care is to avoid causing harm and to practice safely, legally and competently.

Accountability elicits liability and responsibility and evokes duty legally, profes￾sionally and contractually where civil duty arises from a duty of care (Griffith and

Tengnah 2017).

Therefore it is essential that nurses recognise their accountability in their actions

and omissions, and in relation to patient care, they must consider the consequences

of everything they do.

From the earliest days of a nurse’s education and training and subsequent career,

they are involved in medicine management. Although responsibility can increase

and change, the safe and effective management of medicines remains a high prior￾ity. In medicine management, nurses remain accountable even when acting on the

instructions of another practitioner, for example, when administering drugs pre￾scribed by a doctor. Nurses have a professional duty of care not to harm patients and

to act in a way that minimises risk of harm at all times even where, for example, the

prescriber has made the original mistake. This is illustrated in the case of Prendergast

v Sam and Dee (1989) 1 MED LR 36, where both the prescribing doctor and the

pharmacist were held to account for causing harm to the patient who was given the

wrong drug as a result of poor handwriting. It is crucial that nurses take responsibil￾ity for checking and, where necessary, challenging lack of clarity, legibility or any

discrepancy of prescribed medicines or treatment.

Activity 1

Access the link below and review one or two cases that are currently being

heard by the NMC fitness for practice panel. Identify a case that relates to fit￾ness for practice specific to medicine management.

https://www.nmc.org.uk/concerns-nurses-midwives/hearings/hearings￾sanctions/

[Accessed 12 March 2019]

1 Legal and Ethical Issues Associated with Medication

6

All nurses are accountable for their actions, and this includes delegation of the

administration of medicines to other practitioners. It is also possible for more than

one person to be accountable for one action, for example, a nursing student may not

have the experience or knowledge to undertake a task but discharges their account￾ability by making that clear to anyone who attempts to delegate that task to them

(Alexis and Caldwell 2013); this means they must inform others of their limitations;

they cannot use their inexperience to negate their responsibilities. This is illustrated

in the case of Wilsher v Essex H.A. (1987) where the majority of the Court of

Appeal (CA) held that the standard of care required of members of a medical unit was

that of an ordinary skilled person exercising and professing to have that special skill,

but that standard was to be determined in the context of particular posts rather than

the general rank or status of the people filling that post. The duty ought to be tailored

to the acts which the doctor had elected to perform rather than to the doctor himself.

It followed that inexperience was no defence to an action of medical negligence.

1.4 Legal Component of Accountability

The four arenas of accountability relating to the nurse’s duty of care, negligence and

patient harm are:

• Employer (contractual duty)

• NMC (professional duty)

• Civil law (legal duty to patients)

• Criminal law (legal duty to society and the public)

The law is used to regulate professional qualifications, to ensure competent and

safe practice, to protect the rights of patient and the public, to provide a framework

for safe practice and to set rules in society. The law compensates those who are

harmed and restricts or punishes those who act unlawfully.

In healthcare, a standard of care that falls below what is reasonable or acceptable,

or practice that is found to be negligent or reckless, is subject to elements of law in

civil or criminal proceedings. Through a contractual agreement with their employer,

and professional registration, nurses are required to practice in a way that is safe and

competent. Nurses must work within the remit of their job description and organisa￾tional polices and guidelines. It is essential, therefore, that recognising one’s limita￾tions is necessary as this could have an impact on patient safety.

1.5 Duty of Care

In law, citizens are not generally required to owe a duty to be careful to just anyone

(Griffith and Tengnah 2017); however, in certain situations, the nature of the rela￾tionship gives rise to a duty of care (Kent v Griffiths and Others 2000). Nurses have

a duty of care to patients; this is the legal obligation to take reasonable care and to

be careful and not to be careless (Bolitho v City and Hackney H.A. 1997).

S. Ogston-Tuck

7

Clinical negligence is an issue in healthcare practice, and this scenario illustrates

carelessness can happen in any clinical setting. Negligence can be described as any

act of carelessness and lack of regard or lack of insight, which can lead to injury,

harm or loss (Ogston-Tuck 2013). Importantly, it is the degree of patient harm that

determines the significance of the negligent act.

Negligence can lead to patient harm, as in the aforementioned scenario. This may

be regarded as unsafe practice as that falls below an acceptable standard of reason￾able care (Bolam v Friern HMC 1957). Where failings in practice results from an

omission or lack of regard, hence carelessness, it may be deemed negligent. This can

result in a civil claim for compensation or criminal prosecution. In addition, failure

Activity 2

Which element of practice would you consider reckless or careless?

1. Not exercising safe clinical judgement

2. Failing to keep knowledge and skill up to date

3. Not following policy and recommended guidelines

Scenario 1

Working Under Pressure

As a registered nurse, you are working on a busy surgical ward, and all but

one patient has returned from the operating theatre. The patient, who was

scheduled for a knee replacement, is expected back and you prepare the bed￾space and delegate a junior registered nurse to collect Mr. Jones from the recov￾ery unit. Once returned to the ward, the patient complains of nausea; however,

the anaesthetist has not prescribed an anti-emetic. You telephone the anaesthe￾tist who indicates there are ‘standing orders’ for metoclopramide (Maxalon®)

and informs you that the F1 (junior doctor) will be able to sign this order. The

nurse caring for the patient is relieved that she can administer the drug to help

the patient be more comfortable. She administers 20 mg intravenously.

Twenty minutes later, the patient is having difficulty breathing, is diapho￾retic and has developed a rash on his chest and abdomen. The nurse suspects

the patient is having an anaphylactic reaction to the drug. She follows the

treatment algorithm for anaphylaxis, providing oxygen and reassurance and

calling for help, and assisted in administering adrenaline, fluids and antihista￾mines. The patient makes a full recovery but is monitored closely for the next

24 h. It is later identified from the patient’s notes that the patient has a hyper￾sensitivity to metoclopramide.

Who is accountable for the harm caused to Mr. Jones?

1 Legal and Ethical Issues Associated with Medication

8

to communicate effectively or within a team may be also grounds for negligence

(Wilsher v Essex H.A. 1998). For example, a nurse who fails to communicate

concerns with a prescription or change in the patient’s condition in response to

medicine administered carries with it the same risk and associated carelessness.

Nevertheless, without a duty of care, there is no case in law; this is an essential

element in negligence claims. There are three civil wrongs (or torts), which must be

proven for a successful claim of negligence. These are:

• A duty of care is owed.

• The duty of care is breached.

• The breach must have caused damage.

If a nurse has been negligent, generally it is the employer, i.e. the NHS Trust, that

would be sued; however, a claim may also be brought against the individual nurse,

hence the legal duty. Today, healthcare is under public scrutiny, and it is imperative

that all healthcare professionals are aware they can be called to account. In

2017/2018, the NHS Litigation Authority received 10,673 new clinical negligence

claims, compared to 10,686 in 2016/2017 (NHSLA 2018). Failures in the system

where lack of insight, poor leadership and support, lack of skill and competence and

disregard for patient safety can surmount to unnecessary harm and dangerous out￾comes for patients and staff.

An action (claim) for negligence and compensation for the harm can involve the

civil courts; but the three elements of tort must be satisfied and are based on reason￾ableness, foreseeability and a balance of probability. Judges use the ‘Bolam test’

(Bolam v Friern HMC 1957)—this test is a rule of substantive law in determining

not only what amounts to adequate care but also standards of care. Expert evidence

is key in such cases, and these principles apply equally to nurses and other health￾care professionals.

Scenario 2

Unsafe Practice

A staff nurse fails to check the patient’s identity prior to administering a unit

of blood for a transfusion. The blood is administered to the incorrect patient

who suffers a serious transfusion reaction. The patient’s condition deteriorates

rapidly. The patient is transferred to intensive care in a critical condition.

An investigation reveals that the staff nurse had not followed local policy

and blood transfusion guidelines for the safe administration of blood and

blood products.

Consider the nurses actions and professional accountability.

S. Ogston-Tuck