Providing Genetic Nursing Care to Patients With Chronic Illnesses

Pharmacogenomics and chronic illnesses

This article gives a brief history and definition of pharmacogenomics as well as gives some examples of nursing implications as it is translated into clinical practice. According to Cheek et al, “while the terms pharmacogenetics and pharmacogenomics are often used interchangeably, pharmacogenetics is generally used to refer to the role of single genes in drug response while pharmacogenomics is the broader term that encompasses the role of the entire genome, including gene-gene interactions in drug response” (2015, para. 2). Expanding on that, pharmacogenomics is defined as “the knowledge of the specific genetic factors that affect drug response”, with the ultimate goal being the ability to adjust drug doses or suggest alternate therapies to avoid toxicities in patients and yield optimal patient outcomes (Cheek et al 2015). There are several chronic illnesses where the patients would benefit tremendously from this concept. For example, according to Cheek et al, “the most common disease that benefits from pharmacogenomics is cancer. Targeting of specific pharmacological therapies will assist in a greater understanding of the molecular causes of cancer” (2015, para. 12). They also note, “the Clinical Pharmacogenetics Implementation Consortium of the National Institute of Health Pharmacogenomics Research Network recommends that pharmacogenomics information be used in adjusting doses of Warfarin…” (2015, para. 13). Warfarin is often used as anticoagulation therapy in patients diagnosed with certain cardiac arrythmias. And also, per Cheek et al, “pharmacogenomics is also utilized in determining drug efficacy with the antiplatelet agent clopidogrel…” (2015, para. 14). Clopidogrel is often used in patients who have coronary artery disease and have undergone cardiac catheterizations with stent placement to maintain stent patency long-term. Pharmacogenomics is also used in the drug management of mental health disorders  Providing Genetic Nursing Care to Patients With Chronic Illnesses.Cheek et al notes, “this is the second largest therapeutic area that the FDA has identified with pharmacogenomics biomarkers in drug labeling” (2015, para. 25). In summary, the use of pharmacogenomics gives providers the ability to prescribe the precise drug and dosages for maximum efficacy and patient outcomes and minimizes, if not completely eliminates, the risk for adverse drug reactions.

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The nurse’s role is critical because one of our primary duties is safe medication administration. Advocacy involves advocating for and demanding implementation of all available safe administration practices, including precision drug and dosing practices made possible by pharmacogenomics. Nurses also have a duty to communicate with providers results of genetic testing if/when available. Nurses in certain specialties should also be competent to know when genetic testing is actually indicated before certain drugs are prescribed. For example, HIV+ patients with a certain genetic allele can have an adverse drug reaction to the commonly prescribe antiviral medication abacavir, resulting in fatal multi-organ hypersensitivity (Cheek et al, 2015). Nurses have the responsibility of monitoring, assessing, and advocating for the patients, as well as communicating and collaborating with other members of the health care team for the best possible outcomes for the patients. Nurses should also be educating the patients and their families about information that needs to be passed along to other specialties or providers and just so that the patient is aware and informed of his/her own health care information. We also have a duty to safely administer medications based on the correct patient, drug, dose, route and time. We should be monitoring and reassessing for the patient’s response to the drug. Nurses should be communicating immediately with the provider about any adverse drug reactions and provide interventions as indicated. Nurses also have an ethical responsibility to our patients. We have to first ensure that the patient is aware of genetic testing and understands how that information will be used in their health care. We should also ensure that they agree and are willing to have the testing done prior to the actual testing. This is important because it not only affects the patient, but also their family members who may be genetically predisposed, at risk for or managing some of the same conditions or diseases. Cheek et al notes,

The area of precision medicine is here, and the ability to tailor treatment for a myriad of acute and chronic health problems are vast due to the genomic, pharmacogenomic, and genetic explosion. Genetic testing can have a life-altering impact on patients and families. Nurses need to be prepared to first educate patients and families on the value of genetic testing, and then how the information can be used to help families make decisions about the medical management of family members.. Nurses serve as patient advocates for the best possible health outcomes by educating patients about the role pharmacogenomics play in their treatment plan. (2015, para. 31). NURS 4005 NURS 4006: Topics in Clinical Nursing

Pharmacogenomics provides an opportunity for nurses to safely administer the most effective drug and dosage, based on genetics, ultimately resulting in optimal patient outcomes with a minimized risk of adverse drug reactions.

Reference:

Cheek, D., Bashore, L., Brazeau, A. (2015). Pharmacogenomics and implications for nursing practice. Journal of Nursing Scholarship., 47(6), 496-504. Doi: 10.1111/jnu.12168

This week, I chose the subtopic of genomics in patient assessment, but the journal article also falls under the subtopic of genetically competent care for those with chronic illness. This week’s article focuses on the fact that in 2006, the American Nurses Association (ANA) created important competencies for all RNs, but over half of the nurses in practice receive no pre-licensure education on genetics and genomics (G/G) competencies. The article subsequently describes the current utilization of G/G nursing competencies in the acute setting in hospitals and the nurses’ perceptions of them (Newcomb et al., 2019).

The completion of the Human Genome Project has broadened the opportunities for the prevention, diagnosis and management of many diseases resulting in more demands for genetic services. The increasing demands are utilizing nongenetic health professionals to take family histories, conduct family history assessments, interpret results of genetic tests, provide G/G education, and advocate for patient referrals for genetic evaluations. For non-genetic nurses, mostly staff nurses, keeping up with genetic advancements is difficult partially because of the lack of genomic competencies, skills and confidence in integrating G/G into patient education and assessments. Because of the increasing demands of bedside nursing and the education involved to maintain staff nurse competencies, little attention is paid to G/G assessment competencies and patient education (Talwar, et al., 2017). Providing Genetic Nursing Care to Patients With Chronic Illnesses

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Clinical performance for nurses is usually evaluated using competencies that compare nurses’ current work performance with previously established standards of performance. Competencies should reflect the current realities in practice, connecting to performance improvement data and is ever changing. That being said, clinical nurses are expected to master many competencies directly related to their work specific environment, and there are some universal competencies, regardless of practice setting. NURS 4005 NURS 4006: Topics in Clinical Nursing

The ANA created a new set of essential G/G competencies because they usually have a disease or health disorder component. However, most clinical nurses are age 34 and over, with the average age being 48 years old. Many currently practicing nurses who attended nursing school immediately after high school or those who graduated before 2006, received no education about the G/G competencies in their prelicensure programs, but currently, there is very little empirical evidence of that clinical nurses are actually using these competencies. This journal takes a quick look at 10 hospitals over a four -week period and assess in a 38-item questionnaire and direct observation of the EMR to assess for evidence of RN documentation of G/G related care activities (Newcomb, et al., 2019).

While nurses with a graduate degree tended to report more significant competency performance, bedside nurses performed less if any and generally didn’t report any continuing education focusing on G/G. Only six components were performed by most of the respondents in the study with two of them being more concrete activities such as collecting health histories and conducting a physical exam with G/G in mind. Obtaining a family history has been taught as a nursing fundamental for decades, but the ANA suggests going back three generations, which was rarely performed (Newcomb, et al., 2019).

Medical management of chronic illness consumes 75% of money spent on healthcare in the United States making accessible, high quality care a major concern (Shaw, et al., 2014). With the vast amount of ever improving advances in personal  monitors, smart phones, watches, and the plethora of data on the internet, many conditions can be identified early, but an ethical issue remains of misuse of information or patients who may manipulate data to get information or push for a diagnosis of an illness that may not actually be appropriate. Genome sequencing is getting more affordable, allowing for the identification of risks that in some cases can be mitigated if not eliminated completely. However sometimes, more information can cause more ethical dilemmas and complicates decision making because genome sequencing is accurate in some case but can be just a predictor in other cases (Mehrian-Shai, et al.,2015).

Yearly competencies added to the multiple online and in person education for nurses both inpatient and outpatient settings, would be a great step towards obtaining pertinent data and increasing nurse confidence related to the education and integration of G/G. Much of this education should include the ethical complications of more advanced G/G testing. Also, a brief understanding of the role genetics plays in the treatment and prevention of disease should be reviewed each year to help bridge the gap for nurses who need a reminder of competencies and those who didn’t receive it in nursing school prior to actual nursing practice.

References

Mehrian-Shai, R., & Reichardt, J. K. V. (2015). Genomics is changing personal healthcare and medicine: the dawn of iPH (individualized preventive healthcare). Human Genomics, 9, 29. https://doi-org.ezp.waldenulibrary.org/10.1186/s40246-015-0052-0

Newcomb, P., Behand, D., SLEUTEL, M., WALSH, J., BALDWIN, K., & LOCKWOOD, S. (2019). Are genetics/genomics competencies essential for all clinical nurses? Nursing, 49(7), 54–60. https://doi-org.ezp.waldenulibrary.org/10.1097/01.nurse.0000554278.87676.ad NURS 4005 NURS 4006: Topics in Clinical Nursing

Shaw, R. J., McDuffie, J. R., Hendrix, C. C., Edie, A., Lindsey-Davis, L., Nagi, A., Kosinski, A. S., & Williams, J. W., Jr. (2014). Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis. Annals of Internal Medicine, 161(2), 113–121. https://doi-org.ezp.waldenulibrary.org/10.7326/M13-2567

Talwar, D., Tseng, T.-S., Foster, M., Xu, L., & Chen, L.-S. (2017). Genetics/genomics education for nongenetic health professionals: a systematic literature review. Genetics in Medicine : Official Journal of the American College of Medical Genetics, 19(7), 725–732. https://doi-org.ezp.waldenulibrary.org/10.1038/gim.2016.156 NURS 4005 NURS 4006: Topics in Clinical Nursing Providing Genetic Nursing Care to Patients With Chronic Illnesses.