9. Community and Organization Advocacy
Open Resources for Nursing (Open RN)
Nurses advocate for issues in their communities and their organizations.
Addressing Social Determinants of Health
Advocacy is commonly perceived as acting on behalf of a client, but it can be a much broader action than affecting a single client and their family members. Nurses advocate for building healthier communities by addressing social determinants of health (SDOH). SDOH are the conditions in the environments where people live, learn, work, and play that affect a wide range of outcomes. SDOH include health care access and quality, neighborhood and environment, social and community context, economic stability, and education access and quality. Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. See Figure 10.2[1] for an illustration of SDOH.[2]
Specific examples of addressing SDOH include the following goals:
- Improving safe housing and public transportation
- Decreasing discrimination and violence
- Expanding quality education and job opportunities
- Increasing access to nutritious foods and physical activity opportunities
- Promoting clean air and clean water
- Enhancing language and literacy skills[3]
SDOH contribute to health disparities and inequities among different socioeconomic groups. For example, individuals who don’t have access to grocery stores with healthy foods are less likely to have good nutrition, increasing their risk for health conditions like heart disease, diabetes, and obesity, and potentially lowering their life expectancy relative to people who do have access to healthy foods.[4]
One of Healthy People 2030’s goals specifically relates to advocacy regarding SDOH. The goal states, “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.” Across the United States, people and organizations at the local, state, territorial, tribal, and national levels are working hard to improve health and reduce health disparities by addressing SDOH.[5] Read more information about these advocacy efforts in the following box.
Read more about efforts addressing SDOH at Healthy People 2030.
- Economic stability: Factors such as income, employment, and financial security directly affect individuals’ ability to access health care services, afford medications, and maintain healthy lifestyles. Advocates can use this understanding to push for policies that address income inequality, create job opportunities, and provide financial support for those in need. By advocating for economic policies that reduce poverty and enhance financial stability, health care advocates can help mitigate one of the most significant barriers to health.
- Education: Higher levels of education are associated with better health outcomes, as education enhances health literacy, empowers individuals to make informed health decisions, and provides opportunities for better employment. Advocacy efforts can focus on improving access to quality education, promoting health education programs, and supporting lifelong learning initiatives. By addressing educational disparities, advocates can contribute to long-term improvements in health and well-being.
- Social and community context: Strong social support and community connections can improve mental health, reduce stress, and foster a sense of belonging, all of which are essential for overall well-being. Health care advocates can work to strengthen community resources, promote social cohesion, and address issues such as discrimination and violence. Efforts to build safer, more supportive communities can lead to healthier and more resilient populations.
- Access to health and health care: Barriers such as lack of insurance, geographic limitations, and inadequate health care infrastructure can prevent individuals from receiving necessary care. Advocacy in this area can focus on expanding health care coverage, improving health care delivery systems, and ensuring that marginalized populations have access to quality care. By promoting equitable access to health care services, advocates can help reduce health disparities and improve outcomes for underserved communities.
- Neighborhood and environment: Poor housing conditions, lack of safe recreational spaces, and limited access to nutritious food can lead to adverse health outcomes. Advocates can work to improve urban planning, support affordable housing initiatives, and promote policies that ensure access to healthy food options. Creating healthier environments can have a substantial impact on public health.[6] Nursing union goals are typically to advocate for the improvement of benefits, wages, patient safety, and workplace conditions. Advocacy is accomplished by collective bargaining. Collective bargaining refers to the negotiation of wages and other conditions of employment by an organized body of employees. See Figure 10.3[7] for an image of a union worker.
Figure 10.3 Union Worker Although there is no single union that represents all nurses across the country, there are several nursing unions such as the National Nurses United, SEIU United Healthcare, and The United Food and Commercial Workers International Union. The National Nurses United union is the largest nursing union in the United States and has joined with other unions across the country to address unsafe staffing. Read more about these unions in the following box.
Read more about nursing unions:
Nursing unions can provide several potential benefits to the nursing profession. They may improve job security, improve working conditions, negotiate for better pay and benefits, protect seniority, establish staffing ratios, address workplace violence and incivility, and provide a well-defined grievance process. Unionized nurses earn an average of $200-$400 more per week than nonunionized nurses. Unions assist with grievance processes for resolving disagreements between employees and management. Examples of grievances include the promotion of one employee over another who has more seniority, disputes over holiday pay, and problems related to employee discipline.[8]
However, there are also potential disadvantages of unions, such as the cost of dues (up to $90/month per nurse), difficulty in removal of incompetent nurses, mandatory strikes with no pay, the issue of seniority taking precedence over good performance, and creation of working environments that can be adversarial between management and nursing. Additionally, many nursing unions are not organized or led by nurses, causing the belief that some unions are more interested in collecting dues than in improving the work environment for nurses. Although there has been research to determine if unions are good for nurses and good for clients, the findings are not conclusive. Some studies have shown that unionized hospitals have lower mortality rates, but higher failure-to-rescue and pressure injury rates. Another study found that unionized hospitals had higher levels of job dissatisfaction but higher levels of nurse retention.[9],[10]
Workplace Advocacy Models
Nurses can advocate for improvements in the workplace via various mechanisms, such as shared governance and the ANCC Magnet Recognition Program, and by participation in professional organizations. Nurses can also seek legislative solutions for workplace problems by advocating for legislation such as whistleblower protection.[11] Whistleblower protection is further discussed in the "Policy Advocacy" section of this chapter.
Shared Governance
Shared governance refers to a shared leadership model between management and employees working together to achieve common goals. Shared governance models are believed to promote nurses’ empowerment, engagement, autonomy, accountability, and collaboration while also striving to improve patient safety, quality care, and positive outcomes. This style of management encourages and empowers nurses to be part of making decisions that impact their daily work environments. When organizations utilize a shared governance model, employees feel valued and invested in the organization's success. Nurse engagement also improves both staff and client outcomes, such as increased job satisfaction and patient satisfaction.[12] Implementation of a shared governance model has led to organizational cost savings, decrease in meeting times, fewer sick days used by employees, and a decrease in staff turnover.[13] See the following box for an example of effective shared governance.
Example of Effective Shared Governance[14]
A busy telemetry unit wants to address issues with low patient satisfaction scores and an increase in both central line and indwelling catheter days. A quality improvement project is instituted by a multidisciplinary team that works to communicate the project's goals and objectives, respecting each team member's expertise and input. The team initiates daily multidisciplinary rounding on the unit. Six months after the implementation of multidisciplinary rounding, patient satisfaction scores improve, and a decrease in both central line and indwelling catheter days is noted. Multidisciplinary rounding provides a collaborative team approach, acknowledging the expertise and leadership role of each discipline with the same end goal of improving client outcomes.
Magnet Recognition Program
Nurses can advocate for their excellence in the workplace by participating in activities required for Magnet Recognition. As previously discussed in this book, the Magnet Recognition Program is an organizational credential from the American Nurses Credentialing Center (ANCC) recognizing quality client outcomes, nursing excellence, and innovations in professional nursing practice. The Magnet Recognition Program requires nursing advocacy in the areas of technology, education, policies, and process development. This advocacy is accomplished by creating unit-based practice councils who meet regularly to discuss unit policies, practices, and outcomes. Additionally, an organization-wide practice council includes a representative from each unit council and reviews organizational-wide policies and practices. Read more about the Magnet Recognition Program in the following box.
Read more about the Magnet Recognition Program.
Professional Nursing Organizations
Professional organizations provide easy access to nursing advocacy work being done across the nation and the world. There are over 100 local, state, and national organizations that advocate for the nursing profession. Professional nursing organizations may advocate for specific nursing issues in certain areas of practice, such as critical-care nursing (American Association of Critical-Care Nurses, AACN) or broader national nursing issues, such as the American Nurses Association (ANA). Professional organizations also provide opportunities for continuing education, advanced certification, and participation in political action committees. Membership in state and national organizations helps nurses stay up-to-date on current evidence-based practices and research findings.
Media Attributions
- Healthy People 2030 SDOH Graphic Domain Labels
- Debbie_Stabenow_marches_on_Labor_Day_2017_21318919_10155403813215528_8762450224354658172_o
- “Healthy People 2030 SDOH Graphic.png” by U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion is in the Public Domain. Access for free at https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health ↵
- Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health[/footnote Analysis of individuals' social determinants of health provides a holistic understanding of the factors that influence health. By addressing economic stability, education, social and community context, health and healthcare access, and the neighborhood and built environment, advocates can develop comprehensive strategies to improve health outcomes and reduce disparities. Recognizing and addressing SDOH enables healthcare advocates to promote policies and initiatives that create healthier, more equitable communities, ultimately leading to better health for all.
Organization Advocacy
Nurses advocate for organizational issues in the nursing profession and the workplace through participation in unions, collective bargaining, workplace advocacy models, and professional organizations.Unions and Collective Bargaining
A nursing union is a type of labor union that advocates for the interest of its nurse members. According to the Bureau of Labor Statistics, 20 percent of RNs and 10 percent of LPNs/VNs in the United States are union members.[footnote]Rowland, T. (2020, August 26). The pros and cons of nursing unions [Blog]. Soliant. https://blog.soliant.com/nursing/the-pros-and-cons-of-nursing-unions/ ↵Advanced Practice Registered Nurse (APRN): An RN who has a graduate degree and advanced knowledge. There are four categories of APRNs: certified nurse-midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), or certified registered nurse anesthetist (CRNA). These nurses can diagnose illnesses and prescribe treatments and medications.[1] (Chapter 1.4)
ANA Standards of Professional Nursing Practice: Authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. The Standards of Professional Nursing Practice describe a competent level of nursing practice as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.[2] (Chapter 1.3)
ANA Standards of Professional Performance: Standards that describe a competent level of behavior in the professional role of the nurse, including activities related to ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health.[3] (Chapter 1.3)
Basic nursing care: Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.[4] (Chapter 1.4)
Board of Nursing: The state-specific licensing and regulatory body that sets the standards for safe nursing care, decides the scope of practice for nurses within its jurisdiction, and issues licenses to qualified candidates. (Chapter 1.3)
Certification: The formal recognition of specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty. (Chapter 1.4)
Chain of command: A hierarchy of reporting relationships in an agency that establishes accountability and lays out lines of authority and decision-making power. (Chapter 1.4)
Code of ethics: A code that applies normative, moral guidance for nurses in terms of what they ought to do, be, and seek. A code of ethics makes the primary obligations, values, and ideals of a profession explicit. (Chapter 1.6)
Dysphagia: Impaired swallowing. (Chapter 1.4)
Ethical principle: An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). (Chapter 1.6)
Evidence-based practice: A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health consumer’s history and condition, as well as health care resources; and client, family, group, community, and population preferences and values.[5] (Chapter 1.8)
Expressive aphasia: The impaired ability to form words and speak. (Chapter 1.4)
Licensed Practical Nurse/Vocational Nurse (LPN/LVN): An individual who has completed a state-approved practical or vocational nursing program, passed the NCLEX-PN examination, and is licensed by their state Board of Nursing to provide client care.[6] (Chapter 1.4, Chapter 1.5)
Malpractice: A specific term that looks at a standard of care, as well as the professional status of the caregiver.[7] (Chapter 1.6)
Morality: Personal values, character, or conduct of individuals within communities and societies.[8] (Chapter 1.6)
Negligence: A “general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances.”[9] (Chapter 1.6)
Nurse Licensure Compact (NLC): Allows a nurse to have one multistate license with the ability to practice in the home state and other compact states. (Chapter 1.5)
Nursing: Nursing integrates the art and science of caring and focused on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.[10] (Chapter 1.3)
Nurse Practice Act (NPA): Legislation enacted by each state that establishes regulations for nursing practice within that state by defining the requirements for licensure, as well as the scope of nursing practice. (Chapter 1.3)
Patient confidentiality: Keeping your client’s Protected Health Information (PHI) protected and known only by those health care team members directly providing care for the client. (Chapter 1.6)
Primary care: Care that is provided to clients to promote wellness and prevent disease from occurring. This includes health promotion, education, protection (such as immunizations), early disease screening, and environmental considerations. (Chapter 1.4)
Protocol: A precise and detailed written plan for a regimen of therapy.[11] (Chapter 1.3)
Provider: A physician, podiatrist, dentist, optometrist, or advanced practice nurse provider.[12] (Chapter 1.4)
Quality: The degree to which nursing services for health care consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.”[13] (Chapter 1.8)
Quality improvement: Combined and unceasing efforts of everyone–healthcare professionals, clients and their families, researchers, payers, planners and educators–to make the changes that will lead to better client outcomes (health), better system performance (care) and better professional development (learning). (Chapter 1.8)
Registered Nurse (RN): An individual who has graduated from a state-approved school of nursing, passed the NCLEX-RN examination, and is licensed by a state board of nursing to provide client care.[14] (Chapter 1.4, Chapter 1.5)
Safety culture: A culture established within health care agencies that empowers nurses, nursing students, and other staff members to speak up about risks to clients and to report errors and near misses, all of which drive improvement in client care and reduce the incident of client harm. (Chapter 1.3)
Scope of practice: Services that a qualified health professional is deemed competent to perform and permitted to undertake – in keeping with the terms of their professional license. (Chapter 1.1)
Secondary care: Care that occurs when a person has contracted an illness or injury and is in need of medical care. (Chapter 1.4)
Tertiary care: A type of care that deals with the long-term effects from chronic illness or condition, with the purpose to restore physical and mental function that may have been lost. The goal is to achieve the highest level of functioning possible with this chronic illness. (Chapter 1.4)
Unlicensed Assistive Personnel (UAP): Any unlicensed person, regardless of title, who performs tasks delegated by a nurse. This includes certified nursing aides/assistants (CNAs), patient care assistants (PCAs), patient care technicians (PCTs), state tested nursing assistants (STNAs), nursing assistants-registered (NA/Rs) or certified medication aides/assistants (MA-Cs). Certification of UAPs varies between jurisdictions.[15] (Chapter 1.4)
Absorption
The first stage of pharmacokinetics is known as absorption. Absorption occurs after drugs enter the body and travel from the site of administration into the body's circulation. Medications can enter the body through various routes. Common routes to administer medications include the following examples:
- Oral (swallowing an aspirin tablet)
- Enteral (administering medication into the gastrointestinal tract via a nasogastric tube)
- Rectal (administering an acetaminophen suppository)
- Intranasal (spraying allergy medication into the nose)
- Inhalation (breathing in asthma medication from an inhaler)
- Intramuscular (injecting an influenza vaccine into the deltoid muscle)
- Subcutaneous (injecting insulin into the subcutaneous tissue in the abdomen)
- Transdermal (wearing a nicotine patch that is absorbed through the skin)
- Intravenous (administering antibiotics directly into a vein)
First-Pass Effect
When a medication is administered orally or enterally, absorption may be significantly hindered in the gastrointestinal (GI) tract. For example, when medications made of protein are introduced into the GI tract, they can be quickly deactivated by enzymes as they pass through the stomach and duodenum. If some of the drug is absorbed from the intestine into the bloodstream, part of the absorbed portion may be broken down by liver enzymes, whereas the remaining part escapes into the general circulation. The portion of the drug that enters the general circulation will either become protein-bound (and thus inactive) or remain free to circulate and create an action at a receptor site. This entire process that results in reduced concentration of active drug available in an individual's circulation is known as the first-pass effect. Due to the first-pass effect, prescribing providers and nurses administering medications must understand that several doses of an oral medication may be needed before enough free drug stays active in the circulation to exert the desired effect. These metabolic effects are further described in the “Metabolism” section later in this chapter.
Alternate Routes
A workaround to the first-pass effect is to administer medication using alternate routes to the GI tract. Examples of alternative routes that avoid the first-pass effect include transdermal, nasal, inhalation, injection, or intravenous administration of medication. Alternative routes of medication administration bypass the first-pass effect by entering the bloodstream directly or via absorption through the skin or lungs. For example, pain relievers may be administered directly into the bloodstream (referred to as intravenous medications) so they are quickly available for distribution to tissues within the body.
Alternative routes of medication have other potential considerations. For example, injections are often painful and cause a break in the skin, an important barrier to infection. They can also be costly and difficult to administer daily, may cause localized side effects, or contribute to unpredictable fluctuations in medication blood levels.
Transdermal application of medication is an alternate route that has the primary benefit of slow, steady drug delivery directly to the bloodstream, without passing through the liver first. See Figure 1.2[16] for an image of a client self-administering a transdermal patch. Drugs delivered transdermally enter the blood via a meshwork of small arteries, veins, and capillaries in the skin. This makes the transdermal route of drug delivery particularly useful when a medication must be administered over a longer period of time to control symptoms. For example, transdermal application of fentanyl, a pain medication, can provide effective pain management over a several hours; a scopolamine patch can control motion sickness over the duration of a cruise ship vacation; and a nitroglycerin patch is used to prevent chronic chest pain. Despite their advantages, transdermal patches have a significant drawback in that only very small drug molecules can enter the body through the skin, making this application route inappropriate for some types of medications.
Inhaling drugs through the nose or mouth is another alternative route for rapid medication delivery that bypasses the liver. See Figure 1.3 for an image of a client self-administering an inhaler.[17] Metered-dose inhalers have been a mainstay of asthma therapy for several years, and nasal steroid medications are often prescribed for allergy and sinus problems.
Emerging Discoveries and Recent Developments
Researchers are currently exploring alternative methods of drug delivery such as the use of inhaled insulin powders. Afrezza® is an example of an inhaled insulin approved by the Food and Drug Administration (FDA) to assist with blood sugar control. This technology stems from novel uses of chemistry and engineering to manufacture insulin particles of just the right size for absorption. If too large, the insulin particles could lodge in the lungs; if too small, the particles will be exhaled.[18]
Life Span Considerations
Neonate & Pediatric
Gastric absorption in neonates and pediatric clients varies from adults. In infants, the acid-producing cells of the stomach are immature until around the age of one to two years. Additionally, gastric emptying may be decreased because of slowed or irregular peristalsis (coordinated muscle movements of the intestines).
The liver of infants and children is not fully mature, resulting in a decrease in first-pass elimination and subsequently higher drug levels in the bloodstream.[19]
Older Adult
As a natural result of aging, older adults will experience decreased blood flow to tissues within the GI tract. In addition, there may be changes in the gastric (stomach) pH that may alter the absorption of certain medications. Older adult clients may also experience variations in available plasma proteins, which can impact drug levels of medications that are highly protein-bound.
Consideration must also be given to the use of subcutaneous and intramuscular injections in older clients experiencing decreased cardiac output because decreased drug absorption of medications can occur when peripheral circulation is decreased. Additionally, as adults age, they often have less subcutaneous fat, resulting in decreased absorption of medication from transdermal patches that require adequate subcutaneous fat stores for proper absorption.[20]
The box below summarizes route considerations that a nurse should consider when administering medication.
Route Considerations
Oral (PO) or Enteral (NGT, GT, OGT) Ingestion
- Oral route is a convenient route for administration of solid and liquid formulations.
- Additional variables that may influence the rate and extent of absorption include enteric coating or extended-release formulations, acidity of gastric contents, gastric emptying rate, dietary contents, and presence of other drugs.
- First-pass effect: Blood containing the absorbed drug passes through the liver, which can deactivate a substantial amount of the drug and decrease its bioavailability (the percentage of dose that reaches the systemic circulation).
Parenteral Injection
- Subcutaneous and intramuscular administration: Injections can be difficult for clients to self-administer at home or to administer on a daily basis. They can be costly and painful. Injections also cause a break in skin that is an important barrier to infection, can cause fluctuation in drug levels, and can cause localized side effects to skin, such as bruising, redness, bleeding, and swelling.
- Intravenous (IV): IV drugs are fully available to tissues after administration into the bloodstream, offering complete bioavailability and an immediate effect. However, this route requires intravenous access that can be painful to the client and also increases risk for infection. Medications must be administered in sterile fashion, and if two products are administered simultaneously, their compatibility must be verified. There is also an increased risk of toxicity to the kidneys or liver.
Pulmonary Inhalation
- Inhalation allows for rapid absorption of drugs in gaseous, vaporized, or aerosol form through the lung tissue.
- Absorption of particulates/aerosols depends on particle/droplet size, which influences depth of entry through the pulmonary tree to reach the alveoli.
- The ability of the client to create successful inhalation, especially in the presence of bronchospasm, may also influence depth of entry in the pulmonary tree.
Topical and Transdermal Application
- Topical creams, lotions, and ointments are generally used for local effect; transdermal patch formulations are used for systemic effect.
- Absorption through the buccal or sublingual membranes may be rapid and is used for systemic effect.
- Absorption through skin is generally slower but produces a steady, long-term effect that avoids the first-pass effect. However, absorption of medication is affected by blood flow to the skin.[21] For this reason, heat and cold applications should not be used over transdermal medications.
Absorption
The first stage of pharmacokinetics is known as absorption. Absorption occurs after drugs enter the body and travel from the site of administration into the body's circulation. Medications can enter the body through various routes. Common routes to administer medications include the following examples:
- Oral (swallowing an aspirin tablet)
- Enteral (administering medication into the gastrointestinal tract via a nasogastric tube)
- Rectal (administering an acetaminophen suppository)
- Intranasal (spraying allergy medication into the nose)
- Inhalation (breathing in asthma medication from an inhaler)
- Intramuscular (injecting an influenza vaccine into the deltoid muscle)
- Subcutaneous (injecting insulin into the subcutaneous tissue in the abdomen)
- Transdermal (wearing a nicotine patch that is absorbed through the skin)
- Intravenous (administering antibiotics directly into a vein)
First-Pass Effect
When a medication is administered orally or enterally, absorption may be significantly hindered in the gastrointestinal (GI) tract. For example, when medications made of protein are introduced into the GI tract, they can be quickly deactivated by enzymes as they pass through the stomach and duodenum. If some of the drug is absorbed from the intestine into the bloodstream, part of the absorbed portion may be broken down by liver enzymes, whereas the remaining part escapes into the general circulation. The portion of the drug that enters the general circulation will either become protein-bound (and thus inactive) or remain free to circulate and create an action at a receptor site. This entire process that results in reduced concentration of active drug available in an individual's circulation is known as the first-pass effect. Due to the first-pass effect, prescribing providers and nurses administering medications must understand that several doses of an oral medication may be needed before enough free drug stays active in the circulation to exert the desired effect. These metabolic effects are further described in the “Metabolism” section later in this chapter.
Alternate Routes
A workaround to the first-pass effect is to administer medication using alternate routes to the GI tract. Examples of alternative routes that avoid the first-pass effect include transdermal, nasal, inhalation, injection, or intravenous administration of medication. Alternative routes of medication administration bypass the first-pass effect by entering the bloodstream directly or via absorption through the skin or lungs. For example, pain relievers may be administered directly into the bloodstream (referred to as intravenous medications) so they are quickly available for distribution to tissues within the body.
Alternative routes of medication have other potential considerations. For example, injections are often painful and cause a break in the skin, an important barrier to infection. They can also be costly and difficult to administer daily, may cause localized side effects, or contribute to unpredictable fluctuations in medication blood levels.
Transdermal application of medication is an alternate route that has the primary benefit of slow, steady drug delivery directly to the bloodstream, without passing through the liver first. See Figure 1.2[22] for an image of a client self-administering a transdermal patch. Drugs delivered transdermally enter the blood via a meshwork of small arteries, veins, and capillaries in the skin. This makes the transdermal route of drug delivery particularly useful when a medication must be administered over a longer period of time to control symptoms. For example, transdermal application of fentanyl, a pain medication, can provide effective pain management over a several hours; a scopolamine patch can control motion sickness over the duration of a cruise ship vacation; and a nitroglycerin patch is used to prevent chronic chest pain. Despite their advantages, transdermal patches have a significant drawback in that only very small drug molecules can enter the body through the skin, making this application route inappropriate for some types of medications.
Inhaling drugs through the nose or mouth is another alternative route for rapid medication delivery that bypasses the liver. See Figure 1.3 for an image of a client self-administering an inhaler.[23] Metered-dose inhalers have been a mainstay of asthma therapy for several years, and nasal steroid medications are often prescribed for allergy and sinus problems.
Emerging Discoveries and Recent Developments
Researchers are currently exploring alternative methods of drug delivery such as the use of inhaled insulin powders. Afrezza® is an example of an inhaled insulin approved by the Food and Drug Administration (FDA) to assist with blood sugar control. This technology stems from novel uses of chemistry and engineering to manufacture insulin particles of just the right size for absorption. If too large, the insulin particles could lodge in the lungs; if too small, the particles will be exhaled.[24]
Life Span Considerations
Neonate & Pediatric
Gastric absorption in neonates and pediatric clients varies from adults. In infants, the acid-producing cells of the stomach are immature until around the age of one to two years. Additionally, gastric emptying may be decreased because of slowed or irregular peristalsis (coordinated muscle movements of the intestines).
The liver of infants and children is not fully mature, resulting in a decrease in first-pass elimination and subsequently higher drug levels in the bloodstream.[25]
Older Adult
As a natural result of aging, older adults will experience decreased blood flow to tissues within the GI tract. In addition, there may be changes in the gastric (stomach) pH that may alter the absorption of certain medications. Older adult clients may also experience variations in available plasma proteins, which can impact drug levels of medications that are highly protein-bound.
Consideration must also be given to the use of subcutaneous and intramuscular injections in older clients experiencing decreased cardiac output because decreased drug absorption of medications can occur when peripheral circulation is decreased. Additionally, as adults age, they often have less subcutaneous fat, resulting in decreased absorption of medication from transdermal patches that require adequate subcutaneous fat stores for proper absorption.[26]
The box below summarizes route considerations that a nurse should consider when administering medication.
Route Considerations
Oral (PO) or Enteral (NGT, GT, OGT) Ingestion
- Oral route is a convenient route for administration of solid and liquid formulations.
- Additional variables that may influence the rate and extent of absorption include enteric coating or extended-release formulations, acidity of gastric contents, gastric emptying rate, dietary contents, and presence of other drugs.
- First-pass effect: Blood containing the absorbed drug passes through the liver, which can deactivate a substantial amount of the drug and decrease its bioavailability (the percentage of dose that reaches the systemic circulation).
Parenteral Injection
- Subcutaneous and intramuscular administration: Injections can be difficult for clients to self-administer at home or to administer on a daily basis. They can be costly and painful. Injections also cause a break in skin that is an important barrier to infection, can cause fluctuation in drug levels, and can cause localized side effects to skin, such as bruising, redness, bleeding, and swelling.
- Intravenous (IV): IV drugs are fully available to tissues after administration into the bloodstream, offering complete bioavailability and an immediate effect. However, this route requires intravenous access that can be painful to the client and also increases risk for infection. Medications must be administered in sterile fashion, and if two products are administered simultaneously, their compatibility must be verified. There is also an increased risk of toxicity to the kidneys or liver.
Pulmonary Inhalation
- Inhalation allows for rapid absorption of drugs in gaseous, vaporized, or aerosol form through the lung tissue.
- Absorption of particulates/aerosols depends on particle/droplet size, which influences depth of entry through the pulmonary tree to reach the alveoli.
- The ability of the client to create successful inhalation, especially in the presence of bronchospasm, may also influence depth of entry in the pulmonary tree.
Topical and Transdermal Application
- Topical creams, lotions, and ointments are generally used for local effect; transdermal patch formulations are used for systemic effect.
- Absorption through the buccal or sublingual membranes may be rapid and is used for systemic effect.
- Absorption through skin is generally slower but produces a steady, long-term effect that avoids the first-pass effect. However, absorption of medication is affected by blood flow to the skin.[27] For this reason, heat and cold applications should not be used over transdermal medications.
