Module 7 Pharmacology I Medication Administration 1

Module 7 Pharmacology I: Medication Administration 1

Safe Practices in Medication Administration 2

“ 7 Rights” of Safe Medication Administration n n n Right Drug Right Dose Right Time Right Route Right Patient Right Reason Right Documentation 3

“ 7 Rights” (continued) n Right Drug q n Check all orders, labels and confirm that the drug is appropriate for this client/condition Right Dose q Is the dose is appropriate for the drug, age, size and patient condition 4

“ 7 Rights” (continued) n Right Time q n Follow agency policy Right Route q Follow medication order and knowledge of appropriate routes for specific drugs 5

“ 7 Rights” (continued) n Right Patient q n Right Reason q n ALWAYS identify the patient 2 ways (the patient’s room number should not be one of the options) Requires knowledge of medication; knowledge of patient; question appropriateness of order if applicable Right Documentation q Follow agency policy and procedure for immediate documentation = time, route, response 6

Right Documentation n Remember the 5 W’s when documenting medication administration on chart: q q q When (time) Why (include assessment, symptoms, complaints, lab) What (medication, dose, route) Where (site) Was (med tolerated? /helpful to the patient? ) (See Study Guide #2 for additional charting tips and legal aspects of medication documentation) 7

Medication Documentation n n n First, make sure you have the right chart! Never chart a drug before it is administered Documenting includes name of drug, dosage, route, and time Record location when giving parenteral medications Follow agency policy if a medication was not given Document client’s response to the medication 8

Preventing Medication Errors n n n Minimize verbal and telephone orders Refrain from attempting to decipher illegibly written orders Always adhere to the 7 rights Read the label 3 times, checking against the medication administration record Listen to the patient - any concerns are the nurse’s concerns! 9

Preventing Medication Errors (continued) n n n Double check with literature if in doubt about an order Minimize interruptions while processing and preparing medications Do not agree to give medications in an area where you are not experienced 10

Nursing Process and Medication Administration n n Assessment q Medication history, allergies, ability to take med in the form provided? Diagnosis q Is this the right drug, dose, patient, etc? Planning q How will the drug be given? Implementation q Correct route; need for standard precautions? Evaluation q Was the medication effective? 11

Patient Assessments in Medication Administration n n Assess patient variables that might influence drug therapy. Assess drug history prior to the start of a new drug Assess patient’s response to the medication Assess physical parameters prior to administration q Apical pulse, BP 12

Nursing Responsibilities in Medication Administration n n n n Be knowledgeable about medications being administered and being taken by the patient Know what to do in the event of an adverse reaction Verify and clarify orders that seem inappropriate Be knowledgeable and informed concerning agency policies, especially concerning JCAHO’s National Patient Safety Goals Follow standards of nursing practice Observe standard precautions and use medical-surgical asepsis if indicated Confirm “ 7 rights” of safe medication administration Document medication delivery and patient response accurately and appropriately Report adverse events or incidents per agency policy 13

Medical-Surgical Asepsis and Medication Administration n Medical Asepsis q q n Handwashing Standard precautions Surgical Asepsis q Use of sterile supplies 14

National Patient Safety Goals related to Medication Administration n n Use at least 2 patient identifiers just prior to medication administration. (i. e. ask the patient to relate to you their name and date of birth) Verify verbal or telephone orders by verbally reading back the order to the Licensed Independent Practitioner (LIP) out loud. 15

National Patient Safety Goals related to Medication Administration (continued) n n Take action to prevent errors involving sound-alike or look-alike drugs (see agency policy for specific precautions and actions to implement) Label all medications containers both on and off the sterile field. (This applies to syringes of drawn-up medications to be given later, medication cups of oral medications to be given later, etc. ) 16

National Patient Safety Goals related to Medication Administration (continued) n Follow agency policy concerning a comparison of the patient’s currently prescribed medications with those just ordered during the current visit. 17

Legal Implications for Medication Administration n n Nurse’s roles and responsibilities for administration of medications are defined and described by standards of care and the Nurse Practice Act Additionally, there agency specific policies and procedures 18

U. S. Laws Affecting Medication Administration n Food, Drug & Cosmetic Act – (1906) q q n Required accurate labeling and testing for harmful effects 1962 added requirement of proof of safety and effectiveness Harrison Narcotic Act (1914) q q Established legal term “narcotic” Regulated importation, manufacture, sale and use of habit-forming drugs 19

U. S. Laws Affecting Medication Administration (continued) n Durkham-Humphrey Amendment (1952) q Clearly differentiates drugs that can be sold only with a prescription, those that can be sold without a prescription, and those that cannot be refilled without a new prescription. 20

U. S. Laws Affecting Medication Administration (continued) n n Controlled Substance Act- (1970) Also known as: Comprehensive Drug Abuse Prevention and Control Act q q In response to growing misuse/abuse of drugs Categorizes controlled substances Limits how often a prescription can be filled Established government-funded programs to prevent and treat drug dependence 21

U. S. Laws Affecting Medication Administration (continued) n Comprehensive Drug Abuse Prevention and Control Act (continued) q q q Promotes drug education Strengthens enforcement authority Establishes treatment and rehabilitation facilities 22

Schedules of Controlled Substances n n See schedules Study Guide 5 Give an example of one drug from each category 23

Rules Governing Administration of Controlled Substances n n Keep in “burglar” proof containers Double-locked carts or cabinets Accurately complete controlled Substance Inventory form 2 nurses must witness and document when wasting a controlled substance 24

Medication Orders… n n n Should be written clearly, legibly and in easy-to-understand language Should be clarified if unclear – check with direct supervisor first. Should not include blanket, summary statements such as “resume all pre-op orders” 25

Essential Parts of a Medication Order n n n n Patient’s full name Date and time order written Name of medication to be administered Dosage (strength and amount to be given) Frequency of administration Route Number of doses or days medication is to be given Signature of the ordering physician 26

“Do-Not-Use” Abbreviations n n n U for unit IU for international unit Q. D. , qd, QOD, q. o. d. A trailing zero (i. e. 2. 0 mg. Instead use 2 mg) MS, MSO 4, Mg. SO 4 > for greater than < for less than See Study Guide 7 Abbreviations for drug names for more information Apothecary units @ for at C. c. for cubic centimeters Ug for microgram 27

Sources for Locating Drug Information n n n Physician’s Desk Reference National Formulary or Hospital Formulary Pharmacists Drug reference books Pharmacology textbooks Computer-based Indexes 28

Drug Misuse n n Drug misuse - Improper use of any medication which leads to acute/chronic toxicity Drug abuse - Inappropriate intake of a substance 29

Drug Dependence n n n Drug dependence - Person’s reliance on or need to take a substance Physiological dependence – biochemical changes in body tissue, especially the nervous system, which lead to a requirement by the tissues to function normally Psychological dependence – emotional reliance to maintain a sense of well-being 30

Pharmacokinetics n “What the body does to the drug” q q Absorption Distribution Metabolism/Biotransformation Excretion 31

Pharmacokinetics n (continued) Drug Effects q q q Onset- Time it takes for a therapeutic response Peak - Time it takes for maximum therapeutic response Duration of action - Length of time that drug concentration is sufficient for a therapeutic response 32

4 Factors Affecting Absorption n Route of administration and conditions at absorption site q q n Oral medications have slowest rate of absorption IV drugs the fastest Drug dosage and form q q q Enteric coatings delay absorption Liquid form absorbed faster than pills Some parenteral/topicals have additives that delay/prolong absorption 33

Factors Affecting Absorption (continued) n Fat (lipid) solubility q n More lipid soluble the more rapid it’s absorption Gastrointestinal factors q q Gastric emptying time Motility - diarrhea, constipation Presence of food Integrity of GI tract 34

4 Factors Affecting Distribution n n Blood flow Plasma protein binding Amount of the drug Physiological barriers to absorption q q Blood-brain-barrier Placental barrier 35

4 Factors Affecting Metabolism/Biotransformation n Condition of the liver q n Age q n Infants and elderly usually have decreased metabolism of drug Nutritional status q n Liver filters most medications malnutrition Hormones 36

2 Factors Affecting Excretion n Renal excretion q q q n Drugs are filtered in or out by kidneys Renal pathology will decrease excretion Decreased excretion increases circulating blood levels of the drug Liver or lung pathology 37

Drug Half-Life n n n The time it takes for ½ of the original amt of the drug to be removed from the body Useful for determining amount of drug in blood level in relation to amount removed by elimination Used to determine the frequency of drug administration 38

Pharmacodynamics n “How the drug affects the body” q q q Biological, chemical, and physiologic actions of a drug within the body Drugs can promote, block, or turn on/off a response They cannot create a new response 39

Loading Dose n A loading dose is one that is larger than the standard dose: q q It is given at the beginning of drug therapy to quickly raise the blood level of the drug into therapeutic range. It is used when the desired therapeutic response is required more quickly than can be achieved with the standard dose. 40

Maintenance Dose n A maintenance dose is one that continues to keep the drug in the desired therapeutic range: q q It is used after a loading dose. For many drugs, patients receive the maintenance dose both at the start of therapy and throughout therapy. 41

Therapeutic Index n Relates to drug’s margin of safety, the ratio of effective dose to a lethal dose 42

Tolerance n Means that a larger dose is needed to bring about the same response 43

Adverse Effect n Any non-therapeutic response to the drug therapy-consequences may be minor or significant 44

Drug Interactions n Action of one drug on a second drug or other element creating one or more of the following: q q q Increased or decreased therapeutic effect of either or both drugs A new effect An increase in the incidence of an adverse effect 45

Causes of Drug Interactions n n n GI absorption Enzyme induction Renal excretion Pharmacodynamic effects Patient care variables 46

Allergic Reactions n n Allergic reactions are altered physiologic reactions to a drug that occur because a prior exposure to the drug stimulated the immune system to develop antibodies. Anaphylaxis is the most serious allergic reaction. 47

Accumulation n Occurs when the dosage exceeds the amount the body can eliminate through metabolism and excretion Is called toxicity if tissue/organ damage occurs Factors contributing to accumulation: q q Age Underlying disease 48

Toxicity: Evaluating Drug Levels n n n When receiving certain medications, blood samples are drawn to maintain blood levels within a therapeutic margin Peak: draw a peak level 30 min after IV administration and 1 hour after IM administration Trough: draw a trough level just before the next dose (sometimes before the 3 rd dose) 49

Nursing Responsibilities for Toxicity Assess for signs of: n n Ototoxicity: balance and hearing Nephrotoxicity: I & O, proteinuria GI toxicity: diarrhea Neurotoxicity: drowsiness, seizures 50

Patient Teaching n n To grant legal consent to treatment, patients must be informed about drug regimen Assess patient’s knowledge of medication Provide information about purpose of drug, action and side effects Teach how to self-administer drugs and incorporate into daily routines 51

Route of Administration n Depends upon: q q n Drug characteristic Desired responses Each route has advantages/disadvantages 52

Oral Route n n Simple and convenient Relatively inexpensive Can be used by most people Disadvantages: q q Slower drug action Irritation of GI tract 53

Oral Administration n Assess patient q q Can the patient swallow? Crush tablets if appropriate Don’t crush enteric coated or time-released capsules Crushed tablets may be mixed with food 54

Oral Administration (continued) n Preparation q Solid medications can be put in the same cup except when special assessment like blood pressure or apical pulse is required q Unit dose can be kept in original package q Always place bottle or container caps upside down on counters or tables 55

Oral Administration (continued) n Liquid medications q q q Shake to mix Pour away from the label Use the appropriate measuring device like a medicine cup or syringe Avoid alcohol based meds with alcohol addicted persons Use a straw for liquid iron preparations 56

Sublingual and Buccal Administration n n Prevents destruction in the GI tract Allows rapid absorption into the bloodstream Sublingual tablets placed under the tongue; buccal tablets placed between upper or lower molars in cheek area (alternate sides) Instruct patient to allow medication to dissolve & not drink until completely dissolved 57

Topical Administration n n Primarily provides local effect Clean off old medication Apply using appropriate device Special Considerations q q Nitroglycerine (NTG) Transdermal Meds 58

Rectal Administration n Assess the patient q q q GI function and Anal Competence Keep suppository in refrigerator until ready to administer Place patient in left lateral position Lubricate the suppository Insert past the internal sphincter For enemas, have them retain for 20 to 30 minutes. 59

Vaginal Administration n Cleanse perineum Insert applicator 2 inches Cleanse patient after administration 60

Inhalant Administration n n Check vital signs Have patient exhale deeply before activating device Have patient close lips around the mouthpiece without touching it Use spacer device when needed 61

Nasal Administration n n Have patient blow nose Have patient keep head back Push up tip of nose Place tip of administration device slightly inside nose q May cause aspiration 62

Ophthalmic (Eye) Administration n n If possible, use warm solution Administer with patient supine or sitting up with head back Have patient look up Place drop in conjunctival sac Have patient blink to distribute the medication 63

Otic (Ear) Administration n n Position patient with affected side up Straighten ear canal up and back q q n Warm the solution slightly q n Adult: up and back children under 3: pull down and back Mineral oil is sometimes used in advance to soften wax prior to flushing. Instill drops into the ear canal 64

Parenteral Route n n n Refers to any route other than gastrointestinal Commonly: SC, IM, IV Injections Must be prepared, packaged and administered to maintain sterility Multi-dose vials Single dose vials 65

Parenteral Administration n Equipment q q Use only sterile needles and syringes Needles and syringes are available in various gauges and volumes. The larger the syringe the lower the injection pressure For volumes < 1 ml, use TB or I ml syringe Use an insulin syringe for insulin 66

Equipment for Injections n Choice of needle gauge depends upon: q q q n n Route of administration Viscosity of the solution Size of the client Usually: 25 -gauge 5/8 inch needle SC and Intradermal 20 -or 22 -gauge, 1½ inch needle for IM 67

Medications in Ampules & Vials n n Ampules are sealed glass containers The top is broken; medication is removed by needle & syringe (use a filter needle) Unused portions must be discarded Vials with powdered form, follow directions to dilute with sterile water or normal saline 68

Subcutaneous Administration (SQ) n n n Injection of drugs under the skin Used for small volume (1 ml) Absorption is slower Drug action is usually longer Drugs that are irritating to tissues cannot be given SC Common sites: upper arms, abdomen, thighs Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 69

Subcutaneous (continued) n n n Use 25 -27 gauge needle Gather tissue in opposition and pull up slightly Insert needle at 45 or 90 degree angle using a pushing action Do not aspirate If anti-blood clotting agent, do not massage site 70

Intradermal Administration (ID) n n n Use 26 -27 gauge needle Apply traction to skin near site Place needle with bevel upward Inject small wheel at site and withdrawal needle Do not massage Maximum volume = 0. 1 ml Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 71

Intramuscular Administration (IM) n n n Involves injection of drugs into muscle Absorption is more rapid due to blood supply Incorrect injection techniques may damage blood vessels and nerves Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 72

Intramuscular Injection Sites n n Dorsogluteal Ventrogluteal Deltoid Vastus Lateralis Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 73

Intramuscular Administration n Use 21 -22 g needle Insert at 90 degree angle Max volume 5 ml; usually doses of 1 -3 ml 74

Intramuscular Administration n Z-Track q q For solutions irritating to the tissues Pull skin away from site to displace tissue Inject medication Don’t massage after injection Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 75

Intravenous Administration (IV) n n Involves injection of drugs directly into bloodstream Drugs act rapidly Administered through established IV line or direct injection into the vein (in emergencies) Used for intermittent or continuous infusions 76

Intravenous Administration (continued) n Advantages: q q n Client comfort Easy access for nurses Disadvantages: q q Time and skill required for venapuncture Difficulty in maintaining an IV line Greater potential for adverse reactions Possible complications of IV therapy 77

Intravenous Administration (continued) n Assess IV insertion site: q Pain q Redness q Bleeding q Swelling q Dressing dry and intact Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http: //connection. lww. com/products/smeltzer 9 e/imagebank. asp 78

Nursing Care with IV Medications n n Use standard precautions Wipe “port” with alcohol before accessing Strict sterile technique when preparing medication New guidelines require IV securing device, transparent dressing or sterile tape to secure catheter to the patient 79

Nursing Care (continued) n n When discontinuing IV catheter on a client on anticoagulants, prolonged pressure may be required Document as per policy 80

Intravenous Piggyback (IVPB) n n IVPB is a small volume of medication that is attached or “piggybacked” into the port of an existing IV line Alcohol the port before attaching the piggyback tubing 81

Intermittent IV Therapy n n n Patient may have a saline lock (heparin lock) without a primary IV running through it Used just for intermittent medications Flush before and after medication with normal saline 82

Intravenous Push (IVP) Administration n n The medication is pushed into the port by the nurse Before pushing, the nurse must know: q q If the medication is compatible with the existing IV fluid The rate that the push should be given n usually in minutes 83

Intravenous Administration - Equipment n Pumps q Deliver in ml/hour; most pumps deliver to the tenths place (ex: 85. 5 ml/hour) q Check IV site before connecting to pump q Set rate according to physician’s order q Check for kinks or obstructions frequently 84

Central Lines n n Terminate in the jugular vein, subclavian vein, brachial vein or even into the right atrium Strict sterile technique must be followed when accessing these q n Sterile gloves, masks Peripheral intravenous infusion catheter (PICC) 85

Calculating Dosages n Practice the following: Dose on hand = 250 mg Quantity on hand: 1 tablet = 250 mg Desired dose (dose ordered) = 500 mg ? ? = # of tablets required And the answer is…. 86

Calculating Dosages (continued) n 250 1 = 500 (cross multiply and divide) x 500/250 = 2 The answer is 2 tablets 87

Calculating Dosages (continued) n Practice the following (requires conversion): Dose on hand = 250 mg Quantity on hand: 1 capsule = 250 mg Desired dose (dose ordered) = 0. 5 gm ? ? = # of tablets required And the answer is…. 88

Calculating Dosages (continued) n n Convert 0. 5 gm to mg. 1 gm = 1000 mg so 0. 5 gm = 500 mg 250 = 500 (cross multiply and divide) 1 x 500/250 = 2 The answer is 2 tablets 89

Calculating Dosages (continued) n Practice the following (units): Dose on hand = 10, 000 units Quantity on hand: 10, 000 units per 1 ml Desired dose (dose ordered) = 5000 units ? ? = # of ml required And the answer is…. 90

Calculating Dosages (continued) n 5, 000 units = divide) 10, 000 units = x (cross multiply and 1 n 5000/10, 000 = ½ or 0. 5 n The answer is 0. 5 ml 91

Calculating Dosages (continued) n Practice the following (dose based on weight): Medication order: Lovenox 1 mg/kg BID Dose/quantity on hand = 80 mg/ml Patient’s weight = 154 pounds ? ? = # of ml required And the answer is…. 92

Calculating Dosages (continued) n Convert pounds to kilograms (2. 2 lbs = 1 kg) 154/2. 2 = 70 kg n 1 mg x 70 kg = 70 mg n n Cross multiply and divide: 80 mg = 70 mg 70/80 = 0. 8 1 ml = x The answer is 0. 8 ml 93

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery. 94