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MEDICATION ADMINISTRATION

Chapter 35

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6 Rights of Medication• Right Patient

• Right Drug

• Right Dose

• Right Route

• Right Time

• Right Documentation – if it wasn’t documented, it wasn’t done

• #7 -THE RIGHT To REFUSE

The RIGHT Medication

• As the physician prescribed?

• Trade name or generic?

• Does the drug match the MAR (medication administration record)?

• Is the drug appropriate for the patient?

• Does it make sense?

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The RIGHT Dose

• Does the dose of medication in your hand agree with the dose on the MAR?

• Are the mg, mcg, mL the same?

• Is your math correct?• Double check!!

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The RIGHT Patient

• Have you checked using two patient identifiers?– Patient

states…..verifies DOB

– Patient armband – compare to information on MAR

– What if there is no arm band?

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The RIGHT Time

• AM or PM• Q4• Tid• Bid• Qid• Qd• HS

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The RIGHT Route

• PO• IV• SC (SQ)• TRANSDERMAL• RECTAL• IM• Does it make sense?

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RIGHT Documentation

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MOD – Medication on Demand

• The Radio Frequency Identification (RFID) based wrist band

• The first of its kind to be implemented successfully

• Assists nurses by automating the process of administering patient medication

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ROUTES OF ADMINISTRATION

• PO – Per Os/ by mouth

• SL – Sublingual• Buccal• Inhaled• Intranasal• AD/AS/AU - Ears• OD/OS/OU –

Intraocular [eyes]• Topical - Skin

• IO - intraosseous• PR – per rectum• Vaginal• IM - Intramuscular• IV – Intravenous• SC - Subcutaneous

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SYSTEMS OF MEDICATION MEASUREMENT

• METRIC SYSTEM– ml, mg, mcg, gm

• HOUSEHOLD MEASUREMENTS– Tsp, gtts

• APOTHECARY– Drams, grains

• Know conversions/ carry table

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ORAL ADMINISTRATION OF MEDICATION

• SOLID FORMS– CAPLET

– CAPSULE

– TABLET

– GELCAP

– ENTERIC COATED

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ORAL ADMINISTRATION OF MEDICATION

• LIQUID FORMS– ELIXIR

• CONTAINS ALCOHOL EITHER AS INGREDIANT OR FLAVORING

– EXTRACT• SEPARATE FROM BASE INGREDIENT• (VANILLA EXTRACT)

– AQUEOUS SOLUTION/ SUSPENSION• PARTICLES MIXED WITH BUT NOT DISSOLVED IN WATER

– SYRUP• MIXED WITH SUGAR AND WATER

– TINCTURE• MEDICINE IN ALCOHOL BASE

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ORAL ADMINISTRATION OF MEDICATION

• OTHER ORAL FORMS– TROCHE / LOZENGE

• NOT MEANT TO BE SWALLOWED

– AEROSOL• TOPICAL

– SUSTAINED RELEASE

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ORAL ADMINISTRATION

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BUCCAL ADMINISTRATION OF MEDICATION

• BETWEEN THE CHEEK AND GUMS– TABLET– SEMI-SOLID– PASTE– THICK LIQUID

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SUBLINGUAL

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TOPICAL APPLICATION

• SPRAYS– ORAL– TOPICAL– NASAL– INHALED

• Creams/ Ointments

• VAGINAL/RECTAL– SUPPOSITORIES

• EAR DROPS– POSITION EAR

• EYE DROPS

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PARENTERAL ADMINISTRATION

• INTRAMUSCULAR IM• SUBCUTANEOUS SC• INTRADERMAL [like TB test]• INTRAVENOUS IV• INTRAOSEOUS IO• EPIDURAL • INTRATHECAL (SUBARACHNOID SPACE) • INTRAPERITONEAL• INTRAPLEURAL • INTRARTERIAL• INTRARTICULAR [in a joint]

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INTRAMUSCULAR• PAIN MEDICATION

• ANTIBIOTICS

• VACCINATIONS

• SUPPLEMENTS– IRON– B12

IM Injection SitesIM Injection Sites

VentroglutealVentrogluteal

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Vastus Lateralis

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Deltoid Injection

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INJECTION ANGLES

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Subcutaneous injection

Sub Q administration sites

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Intradermal InjectionIntradermal Injection

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Syringes – NOT interchangeable

Sizes of NeedlesSizes of Needles

Length 3/8” to 3”Gauge 30 – 1920-22G, 1-1.5” for IM25-30G, 3/8-1/2” for

SQ

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Nursing Roles

• Legal and Ethical implications• Know your meds

– Pharmacokinetics:• Because food, other drugs, disease, age affect

absorption, distribution, metabolism, excretion

– Actions– Interactions– Routes– Measurement and Calculation, conversions– Documentation

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Responsibilities

• Prescribe – APN

• Correct drug and dose [range]

• Effects and implications

• Why med is ordered for pt

• Monitor effects – intended and other

• Reactions

• Education

Critical Thinking

• Knowledge: understand why you are giving a med; if you don’t know, look it up

• Experience: skills become more refined

• Attitudes: take adequate time to prepare and administer

• Standards: ensure safe practice– 6 Rights

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Components of Medication Orders

• Client’s full name• Date and time that the order is written• Medication name• Dose• Route• Time and frequency of administration• PRN orders must have a reason• Signature

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Test Your Knowledge

• The nurse is transcribing the physician’s orders for the newly admitted client’s medications. For which of the following orders would the nurse need clarification prior to administering the medication?

A) Digoxin 0.125 mg po daily

B) Lasix 40 mg. po bid

C) Tylenol 650 mg. po PRN

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Types of Medication Action

Therapeutic effect:Therapeutic effect:Expected or predictableExpected or predictable

Side effect:Side effect:Predictable and often Predictable and often unavoidableunavoidable

Adverse effect:Adverse effect:Unintended, undesirable, Unintended, undesirable, and often unpredictable and often unpredictable severe responsesevere response

Toxic effect:Toxic effect:Medication Medication accumulates in the accumulates in the blood streamblood stream

Idiosyncratic reaction:Idiosyncratic reaction:Over- or under-reaction to Over- or under-reaction to a medicationa medication

Allergic reaction:Allergic reaction:Unpredictable response Unpredictable response to a medicationto a medication

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Medication Interactions• Occur when one medication modifies the action

of another

• A synergistic effect occurs when the combined effect of two medications is greater than the effect of the medications given separately.– Can be beneficial: Tylenol and Codeine

– ETOH and antihistimines, antidepressants, or narcotics (all CNS depressants)

– HTN may be treated with diuretic and vasodilator

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Medication Dose Responses

Serum half-life:Serum half-life:Time for serum medication Time for serum medication concentration to be halvedconcentration to be halved

Onset:Onset:Time it takes for a Time it takes for a medication to produce a medication to produce a responseresponse

Peak:Peak:Time at which a medication Time at which a medication reaches its highest effective reaches its highest effective concentrationconcentration

Trough:Trough:Time at which drug is at its Time at which drug is at its lowest amount in the serumlowest amount in the serum

Duration:Duration:Time medication is present Time medication is present in concentration great in concentration great enough to produce responseenough to produce response

Plateau:Plateau:Blood serum concentration is Blood serum concentration is reached and maintainedreached and maintained

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Effects of Nutrition on DrugsGrapefruit Can cause toxicity when taken

with cisapride, carbamazepine, diazepam, verapamil, amiodarone, lovastatin

Vitamin K Decrease effectiveness of warfarin

Tyramine (found in cheese, beer, dried sausage, sauerkraut)

In combination with MAOI meds (Nardil, Parnate, Marplan) creates increase in epinephrine HA, ↑ P, ↑ BP death

Milk Interferes with absorption of tetracycline antibiotics

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Systems of Medication Measurement

• Requires the ability to compute medication doses accurately and correctly

• Metric system: organized in units of 10

• Apothecaries: older than metric

• Household system: least accurate

• Solution

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Insulin Preparation

• Rapid, short, intermediate, and long acting• Know onset, peak and duration (see page 743)• ONLY regular insulin can be given IV• Sliding scale based on blood glucose • Gently roll cloudy• DO NOT SHAKE• Prepare last and administer first if mixed because

regular can become “contaminated” and action can be affected– CLEAR to CLOUDY

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Drug Calculations

Dose Ordered X amount = amount to

dose on hand on hand administer

1. Look at order + available concentration

2. Ballpark estimate

3. Calculate – paper + calculator

4. Check math, compare to estimate

Convert to same units [mcg, mg]

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Examples• Order: Digoxin 12.5mg PO daily• On hand: 25 mg tablets1. Change to same units if needed [mg= mg]2. Put in formula: 12.5 X 1 tab = ?

25 amount to give

3. Estimate: 12.5 is about ½ of 25 4. Solve: ½ X 1 = ½ tab5. Check estimate – ½ = ½

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Wait!

• You’re not done yet:

• Nursing implications for Digoxin:– Assess and record apical HR and B/P– Hold for systolic B/P < 90, HR <60– Know WHY– Know action of Digoxin– Document HR, B/P, dose given or held, time

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Example 2

• Order: APAP gtts 5mg/kg q 4° PO fever/pain

• Available: 80mg/0.8ml [= 100mg/1ml]

• Wt is 3 kg

• 5 mg X 3 kg = 15 mg dose

• Estimate: 100 mg in 1 ml, dose is 15 mg; will be very small dose - < 1 ml

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Solve

15ml [ordered] X 1ml = ? amount

100mg [on hand] to give

15mg/100mg X 1 ml = 0.15ml

Check – close to estimate? [if I mess up my math and get 1.5 ml, estimate will catch me]

Administer and document

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PRACTICE

• You CANNOT Practice medication calculations too much

• KEY skill for success in school & practice

• PRACTICE, PRACTICE, PRACTICE

• Know conversions, abbreviations

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Abbreviations to Avoid

• Trailing Zero e.g. 1.0ml [read as 10ml]

• Lack of leading zero e.g. .1mg [read as 1mg]

• X3D ?? Three doses or three days?

• Drug abbreviations MgSO4 – [mag sulfate]– Read as Morphine Sulfate [MSO4]

• Similar Drug names – clarify [Norvasc/Norflex, Fosamax/ Flomax]

• Handwritten Orders/ MARS – Always Clarify

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Medication References

• Book form – – In med room, on Pyxis

• Electronic –– Available for PDA, Itouch, Iphone

The Nursing Process and Med Administration

• Assessment– Medical history– Allergies– Medication data– Diet history– Client’s perceptual or coordination problems– Client’s current condition– Client’s attitude about medication use– Client’s knowledge and understanding of medication

therapy– Client’s learning needs

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Nursing Diagnoses

• Anxiety• Ineffective health maintenance• Health-seeking behaviors• Deficient knowledge (medications)• Noncompliance (medications)• Disturbed visual sensory perception• Impaired swallowing• Effective therapeutic regimen management• Ineffective therapeutic regimen management

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Planning

• Minimize distractions or interruptions when preparing and administering meds

• This will limit errors

• Prioritize care when administering meds

• Collaboration– Prescriber– Pharmacist– Case manager/social worker

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Goals• Generally: safe administration, knowledge

• Pt will demonstrate safe and effective technique for preparing sliding scale insulin based on blood sugar within 24 hours

• Pt will correctly demonstrate subcutaneous insulin administration before discharge

• Pt will verbalize understanding of side effects of prescribed medications after this teaching session

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Goals, con’t

• You must monitor a client’s response to meds on an on-going basis– Goal is not evaluated just once in practice– E.g. Pain is 3/10 in 30 minutes – good; keep

checking

• The goals of safe and effective med administration involve the client’s response to therapy and ability to assume responsibility for safe self-care

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Interventions

• Administer medications per orders

• Assess need for PRN meds

• Assess/monitor medication effects [side effects, desired effect, toxic effects]

• Teach/ educate pt/family –– How to measure accurately– Administration [safety]– Side effects, when to call DR

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Evaluation

• Was goal met? Partially met? Not met?

• Pt correctly calculates insulin [sliding scale] based on BG

• Demonstrates safe preparation and administration

• Verbalizes side effects

• Asks for pain medication when pain 3/10

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Revising Plan

• 1. If short term goal was met, reinforce, continue, or reset goal [increase independence, etc]

• 2. if partially met, reinforce teaching, promote safety, assess what is needed

• 3. Goal not met? Assess why not, change method, add [pain med plus ice and rest]

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Special Considerations

• Infants and children– Vary in age, weight, surface area and the ability to absorb,

metabolize, and excrete meds– Lower doses; special calculations– Alternative forms, such as liquids or elixirs Psychological

prep

• Older adults– Simplify– Assess swallowing– Some have greater sensitivity

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Test Your Knowledge

• The nurse is teaching a client how to prepare 10 units of regular and 5 units of NPH insulin for injection. In what order should the nurse instruct the client to do the following?

A) Inject air into the regular insulin

B) Inject air into the NPH insulin

C) Withdraw the regular insulin

D) Withdraw the NPH insulin

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Intravenous Administration

• Nurses administer meds IV in the following ways:– As mixtures within large volumes of IV fluids (Banana bag)

– By injection of a bolus or small volume of med through an existing IV line or intermittent venous access (heparin lock/saline lock/buff cap)

– By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line

• You are responsible for reading more about this in your text as there may be questions on the HESI

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Peripheral IV

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IV Solution and Pump

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Patient Controlled Analgesia (PCA)

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Central Venous Catheters

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Test Your Knowledge

• If a client who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects which of the following?

A) SepsisB) PhlebitisC) InfiltrationD) Fluid overload

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IV Care• PICC lines, central lines should be marked –

treated differently

• Disinfect skin [surgically] prior to starting IV; otherwise medical asepsis

• Scrub the hub 15 seconds each time

• PICC – surgical asepsis for dressing changes

• Central lines are conduits [like Foleys] – high infection risk

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