Pharmacological and Parenteral Therapies Study Guide for the NCLEX-RN Exam

General Information

This section of the NCLEX exam, Pharmacological and Parenteral Therapies, falls under the umbrella category of Physiological Integrity. This section focuses on medications and alternative therapies available in healthcare. You will need to know about medication dosages, contraindications, administration routes, side effects, and pain management. Other topics may include questions regarding blood products and parenteral nutrition. Below are the listed major concepts covered in this category.

Medication Effects

Administering medication is much more than “giving” clients medicine. It requires a substantial amount of knowledge about each medication, including the potential effects (both intended and otherwise), interactions with other medications, and a thorough understanding of the patient’s health status, including the ability to tolerate each medication.

Adverse Effects

Adverse effects are undesired, harmful reactions of medications that may occur after a medication is given. These effects may be mild, moderate, or severe and can significantly impact the client. Nurses are responsible for assessing and monitoring clients, their medication regimen, and any adverse effects related to their medications or other therapies. Common signs of adverse effects include allergic reaction (anaphylaxis), skin, respiratory, gastrointestinal and/or circulatory changes. Other, more severe adverse effects include birth defects, hospitalization, coma, and even death. Nurses must know how to recognize these symptoms and initiate any needed, appropriate treatment steps.

Contraindications

Every medication has a list of conditions in which its use is not acceptable or safe. Common conditions that have medication contraindications include pregnancy, organ dysfunction, and allergy/sensitivity. Some medication contraindications are indicated by the category of medication, such as with the pregnancy categories: A, B, C, D, and X. Some medications are contraindicated with foods, such as grapefruit, Vitamin K, alcohol, and specific herbs (St. John’s Wort, Ginseng, Black Cohosh, Ginkgo Biloba). Other medications are contraindicated when the client is already on a specific medication regimen. The nurse must investigate the full medication list of the client, communicate current and future medication plans with the provider, and provide ample education to avoid medication contraindications.

Side Effects

Side effects are very similar to adverse effects. Side effects can occur in addition to the main intended effect of a medication or therapy. Some of the most common side effects for medications include headache, abdominal pain, nausea, vomiting, diarrhea, constipation, dizziness, drowsiness, lethargy, insomnia, and dermatitis. Many medications have very specific side effects and should be studied in preparation for the NCLEX exam.

Clients should be educated on the most common side effects to increase their awareness and communication of these effects, should they occur. Some side effects may be treated with counter therapies, such as prescribing an anti-nausea medication with medications known to cause nausea or adding a probiotic supplement to take with antibiotics to help prevent or lessen diarrhea. When clients experience side effects, the nurse is responsible for discussing these changes with the ordering provider to determine if supportive or alternative therapies need to be considered.

Interactions

A thorough medication history is necessary to fully assess for any unwanted medication interactions. The nurse should discuss the usage of all prescription medications, over-the-counter (OTC) therapies, and other natural or herbal supplements with the client. Many clients unknowingly add incompatible complementary therapy, dietary changes, over-the-counter medications, and/or herbal supplements to their normal medication regimen, increasing their risk for adverse effects. In the hospital, some intravenous fluids will interact with prescribed medications and any incompatibilities should be identified and discussed with the ordering provider.

Nurse Responsibilities

The nursing responsibilities related to medication and fluid administration extend well beyond those listed above. Nurses are key in discussing medication names, dosages, rationales, intended effects, unintended effects, and contraindications with their clients. Nurses also help educate patients on how to take their medications; which ones need to be taken with or without food; how often to take their medications; and any additional specific instructions. Patients should be instructed when to call to report adverse reactions or concerns about side effects.

Sometimes, because of the adverse effects, clients struggle with medication compliance and may abruptly stop or change their medications without medical orders to do so. The nurse should be aware of any medication changes and have an open communication plan with the ordering provider to help maximize the therapies of the client with minimal adverse reactions. Lastly, nurses are responsible for documenting all the discussions with both the client and ordering providers. Documentation is critical for any medical observations, client interactions, adverse reactions, nursing interventions, and/or emergency interventions performed.

Blood and Blood Products

The administration of blood and blood products is common in the hospital setting. Patients may need blood and blood products for a variety of reasons including hypovolemia, anemia, clotting disorders, platelet deficiencies, and trauma. Broad knowledge of blood type, blood administration protocols, and blood products is crucial.

Prior to Administration

The single, most important step of administering blood and blood products is proper patient identification. Each facility will have specific guidelines to follow to reduce errors in blood product administration. In general, the following steps should be taken:

Identify the proper patient and reconcile the patient’s name and medical record with the information on the ordered blood product.
Confirm that the ordered blood product matches the actual blood product.
Check the blood type of the patient with the blood type of the product to be infused to ensure compatibility. This is called cross-matching.
Verify that the blood product(s) is/are not expired.
Lastly, confirm that patient consent has been obtained and is properly documented.

This entire process is usually completed by a two-nurse team to help prevent any errors or missed steps.

Administration

After following the above steps for proper identification of the patient, product, and consent, the nurse should prepare for the administration of the designated blood product.

Patient Evaluation

Appropriate venous access to receive the blood product(s) needs to be identified and/or obtained. The ideal catheter gauge to deliver blood is an 18 gauge to 20 gauge. Central venous access devices may also be used for blood product administration. Larger bore or central intravenous catheters allow the blood product to be administered without clumping, crushing, or shredding of any of the blood components. Always ensure that any existing line is patent and functional prior to initiating an infusion.

Documentation

All aspects of the administration of blood and blood products will need to be documented. This will include (at a minimum):

All steps of the verification process
The exact times of the infusion (starting and stopping)
Vital signs of the patient at initiation of infusion and at set intervals throughout the infusion
All information on the blood product that was administered
All information about the intravenous line that was used for the infusion
All instructions given to the patient before, during, and after the procedure

Administration and Patient Response

There are a number of potential adverse patient reactions to the administration of blood and blood products.

Mild to moderate adverse reactions include localized reactions around the intravenous line, urticaria, rash, pruritus, flushing, fever, restlessness, tachycardia, palpitations, mild dyspnea, and headache.

Severe, and potentially life threatening, adverse reactions include rigors, severe hypotension, hematuria, unexplained bleeding (disseminated intravascular coagulation - DIC), anxiety, chest pain, respiratory distress, and anaphylaxis.

The first step in any concern for a transfusion reaction is to stop the blood product infusion. This step is then quickly followed by interventions as designated by the protocols in place at individual facilities.

Central Venous Access Devices

Several types of central venous access devices are available for patients. Central lines are used for direct administration of intravenous medications, intravenous fluids, and/or blood products to the central venous system. Common locations for central venous access devices include access to the superior vena cava, inferior vena cava, subclavian vein, femoral vein, and internal jugular vein. Central venous access devices have specific instructions for use, care, and maintenance of the devices.

Patient Education

Many patients will be familiar with peripheral venous access, where short-term intravenous catheters are used to administer intravenous medications and fluids. Some patients, though, will require longer-term access or have medications ordered that are caustic to the peripheral venous paths. These patients qualify for the placement of central venous access devices.

Central venous access devices allow intravenous medications, fluids, and blood products to release into the robust central venous system, instead of the more delicate peripheral venous system. Common reasons for needing a central venous access device include long-term intravenous antibiotic therapy, chemotherapy, parenteral nutrition (TPN), and simultaneous intravenous medication administration.

Access Devices

A tunneled catheter is placed in a central vein (usually the subclavian), then “tunneled” through the skin where it exits somewhere on the chest. The “tunnel” provides stability and helps to provide an infection barrier for long-term use of this type of device. Examples include a Hickman®, Groshong®, or Broviac® catheter.

An implanted port is also tunneled beneath the skin, and a catheter is threaded into the superior vena cava. The port can be placed subcutaneously and accessed as needed. Examples of this type of device are the PowerPort®, Port-A-Cath®, and SlimPort® Dual-Lumen Rosenblatt™.

A peripherally inserted central catheter (PICC) is usually placed above or below the antecubital area on the non-dominant arm and then advanced through the peripheral vein until the tip rests in the superior vena cava or cavoatrial junction. These lines may be left in place for long periods.

Access Maintenance

Nurses caring for patients with these devices will need to know how to care for them. Since these central venous access devices are in place long-term, cleaning and maintenance of the line will be required. Strict sterile technique is always required when accessing the line or changing the dressing of a central venous device. Chlorhexidine solution is often used for cleaning the individual lumens and insertion site of the device.

Nurses and patients alike should wear a face mask when accessing the line or changing the dressing. The device line(s) may need to be routinely “locked” or flushed with normal saline or low-concentration Heparin when not in use to prevent clotting of the catheter. Dressing changes should also be performed every 2–7 days, depending on the type of dressing used and protocol of the facility.

Dosage Calculation

Medication dosage calculation requires familiarity with basic arithmetic, ratio and proportion, and algebra. Different measurements systems exist in the world, including the metric system, household measurements (teaspoons, tablespoons, cups, etc.), and apothecary measurements (ounce, minim, dram, etc.). In medicine, most adult doses differ from pediatric doses for the same medication. While adult medication follows a standard dosing guideline, most pediatric medications follow weight-based dosing. It is critical for nurses to know and understand how medications are dosed, which measurements to use, and provide the education needed for patients to understand the same.

Calculations

Many medication dosages, especially in the pediatric population, are based on body weight in kilograms (kgs). To convert weight from pounds to kilograms, simply divide the weight in pounds by 2.2. To find the dose of a medication, take the prescribed unit (mg, ml, cc, etc.) of the medication and multiply it by the patient’s weight in kilograms.

Depending on whether the prescribed order is for a total daily dose or multiple timed doses, the nurse will be responsible for making sure the right dose is given at the right time, to the right patient. If trying to figure out how much of a medication to give at each dose, the total daily dose should be divided by the number of times the dose is given during the day.

Doses may be given once daily (QD), twice daily (BID), three times a day (TID), or four times a day (QID). If scheduled at specific times, doses may be given at specific hourly intervals or before or after significant events, such as meals or before bed (HS). The use of the abbreviations given in the previous two sentences are generally not recommended. They are provided for informational purposes only. All medication orders with confusing or unclear abbreviations should be questioned and clarified with the ordering provider.

Intravenous fluids are given over a period of time. The rate of delivery must be calculated in order to give the appropriate medication dosage in the ordered amount of time. To calculate the amount of time in which an infusion should be given, take the total volume of the solution divided by the total time in minutes in which it should be given and multiplied by the drop/drip rate factor of the IV tubing being used. There are two types of IV tubing: microdrip (60 gtts/mL) and macrodrip (10–20 gtts/mL).

Decision Making

When performing calculations for medication and solution dosage, critical thinking skills are required to guide decision making. While calculation errors will inevitably occur, calculation results should be critically analyzed to make sure they make sense for the order and the client. Nurses need to carefully observe in which units their medications are prescribed and maintain continuity of those units throughout the medication calculation.

Many medications and therapy calculations require an independent two-nurse double-check prior to medication administration. This helps to eliminate many calculation errors and ensure appropriate wasting of specific products. Independent double checks are required for high alert medications and infusions such as narcotics, insulin infusions, heparin infusions, chemotherapy, blood products, parenteral nutrition, and titrated infusions.