1 module 7 pharmacology i: medication administration

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Module 7

Pharmacology I:Medication Administration

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Safe Practices in Medication Administration

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“7 Rights” of Safe Medication Administration

Right Drug Right Dose Right Time Right Route Right Patient Right Reason Right Documentation

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“7 Rights” (continued)

Right Drug Check all orders, labels and confirm that

the drug is appropriate for this client/condition

Right Dose Is the dose is appropriate for the drug,

age, size and patient condition

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“7 Rights” (continued)

Right Time Follow agency policy

Right Route Follow medication order and knowledge of

appropriate routes for specific drugs

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“7 Rights” (continued)

Right Patient ALWAYS identify the patient 2 ways (the patient’s

room number should not be one of the options)

Right Reason Requires knowledge of medication; knowledge of

patient; question appropriateness of order if applicable

Right Documentation Follow agency policy and procedure for

immediate documentation = time, route, response

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Right Documentation

Remember the 5 W’s when documenting medication administration on chart: 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)

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Medication Documentation 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

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Preventing Medication Errors

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!

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Preventing Medication Errors (continued)

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

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Nursing Process and Medication Administration Assessment

Medication history, allergies, ability to take med in the form provided?

Diagnosis Is this the right drug, dose, patient, etc?

Planning How will the drug be given?

Implementation Correct route; need for standard

precautions? Evaluation

Was the medication effective?

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Patient Assessments in Medication Administration

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 Apical pulse, BP

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Nursing Responsibilities in Medication Administration 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

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Medical-Surgical Asepsis and Medication Administration

Medical Asepsis Handwashing Standard precautions

Surgical Asepsis Use of sterile supplies

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National Patient Safety Goals related to Medication Administration 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.

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National Patient Safety Goals related to Medication Administration (continued) 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.)

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National Patient Safety Goals related to Medication Administration (continued) Follow agency policy concerning a

comparison of the patient’s currently prescribed medications with those just ordered during the current visit.

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Legal Implications for Medication Administration

Nurse’s roles and responsibilities for administration of medications are defined and described by standards of care and the Nurse Practice Act

Additionally, there are agency specific policies and procedures

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U.S. Laws Affecting Medication Administration Food, Drug & Cosmetic Act – (1906)

Required accurate labeling and testing for harmful effects

1962 added requirement of proof of safety and effectiveness

Harrison Narcotic Act (1914) Established legal term “narcotic” Regulated importation, manufacture, sale

and use of habit-forming drugs

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Durkham-Humphrey Amendment (1952) 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.

U.S. Laws Affecting Medication Administration (continued)

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Controlled Substance Act- (1970) Also known as: Comprehensive Drug

Abuse Prevention and Control Act 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

U.S. Laws Affecting Medication Administration (continued)

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Comprehensive Drug Abuse Prevention and Control Act (continued) Promotes drug education Strengthens enforcement authority Establishes treatment and rehabilitation

facilities

U.S. Laws Affecting Medication Administration (continued)

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Schedules of Controlled Substances

See schedules Study Guide 5 Give an example of one drug from each

category

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Rules Governing Administration of Controlled Substances

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

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Medication Orders…

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”

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Essential Parts of a Medication Order 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

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“Do-Not-Use” Abbreviations 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, MSO4, MgSO4 > for greater than < for less than Abbreviations for drug names Apothecary units @ for at C.c. for cubic centimeters Ug for microgram

See Study Guide 7 for more information

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Sources for Locating Drug Information Physician’s Desk Reference National Formulary or Hospital

Formulary Pharmacists Drug reference books Pharmacology textbooks Computer-based Indexes

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Drug Misuse

Drug misuse - Improper use of any medication which leads to acute/chronic toxicity

Drug abuse - Inappropriate intake of a substance

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Drug Dependence

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

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Pharmacokinetics

“What the body does to the drug” Absorption Distribution Metabolism/Biotransformation Excretion

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Pharmacokinetics (continued)

Drug Effects 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

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4 Factors Affecting Absorption Route of administration and conditions

at absorption site Oral medications have slowest rate of

absorption IV drugs the fastest

Drug dosage and form Enteric coatings delay absorption Liquid form absorbed faster than pills Some parenteral/topicals have additives

that delay/prolong absorption

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Factors Affecting Absorption (continued)

Fat (lipid) solubility More lipid soluble the more rapid it’s

absorption Gastrointestinal factors

Gastric emptying time Motility - diarrhea, constipation Presence of food Integrity of GI tract

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4 Factors Affecting Distribution Blood flow Plasma protein binding Amount of the drug Physiological barriers to absorption

Blood-brain-barrier Placental barrier

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4 Factors Affecting Metabolism/Biotransformation

Condition of the liver Liver filters most medications

Age Infants and elderly usually have decreased

metabolism of drug Nutritional status

malnutrition Hormones

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2 Factors Affecting Excretion Renal excretion

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

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Drug Half-Life

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

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Pharmacodynamics

“How the drug affects the body” 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

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Loading Dose

A loading dose is one that is larger than the standard dose: 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.

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Maintenance Dose

A maintenance dose is one that continues to keep the drug in the desired therapeutic range: It is used after a loading dose. For many drugs, patients receive the

maintenance dose both at the start of therapy and throughout therapy.

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Therapeutic Index

Relates to drug’s margin of safety, the ratio of effective dose to a lethal dose

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Tolerance

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

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Adverse Effect

Any non-therapeutic response to the drug therapy-consequences may be minor or significant

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Drug Interactions

Action of one drug on a second drug or other element creating one or more of the following: Increased or decreased therapeutic effect

of either or both drugs A new effect An increase in the incidence of an adverse

effect

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Causes of Drug Interactions

GI absorption Enzyme induction Renal excretion Pharmacodynamic effects Patient care variables

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Allergic Reactions

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.

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Accumulation

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: Age Underlying disease

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Toxicity: Evaluating Drug Levels 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 3rd dose)

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Nursing Responsibilities for ToxicityAssess for signs of:

Ototoxicity: balance and hearing Nephrotoxicity: I & O, proteinuria GI toxicity: diarrhea Neurotoxicity: drowsiness, seizures

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Patient Teaching

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

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Route of Administration

Depends upon: Drug characteristic Desired responses

Each route has advantages/disadvantages

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Oral Route

Simple and convenient Relatively inexpensive Can be used by most people Disadvantages:

Slower drug action Irritation of GI tract

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Oral Administration

Assess patient Can the patient swallow? Crush tablets if appropriate Don’t crush enteric coated or time-released

capsules Crushed tablets may be mixed with food

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Oral Administration (continued)

Preparation Solid medications can be put in the

same cup except when special assessment like blood pressure or apical pulse is required

Unit dose can be kept in original package

Always place bottle or container caps upside down on counters or tables

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Oral Administration (continued)

Liquid medications 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

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Sublingual and Buccal Administration 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

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Topical Administration

Primarily provides local effect Clean off old medication Apply using appropriate device Special Considerations

Nitroglycerine (NTG) Transdermal Meds

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Rectal Administration

Assess the patient 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.

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Vaginal Administration

Cleanse perineum Insert applicator 2 inches Cleanse patient after administration

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Inhalant Administration

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

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Nasal Administration

Have patient blow nose Have patient keep head back Push up tip of nose Place tip of administration device

slightly inside nose May cause aspiration

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Ophthalmic (Eye) Administration

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

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Otic (Ear) Administration

Position patient with affected side up Straighten ear canal up and back

Adult: up and back children under 3: pull down and back

Warm the solution slightly Mineral oil is sometimes used in advance to

soften wax prior to flushing. Instill drops into the ear canal

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Parenteral Route

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

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Parenteral Administration

Equipment 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

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Equipment for Injections

Choice of needle gauge depends upon: 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

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Medications in Ampules & Vials 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

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Subcutaneous Administration (SQ) 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

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Subcutaneous (continued)

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

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Intradermal Administration (ID) 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 = 0.1ml

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Intramuscular Administration (IM) Involves injection of drugs into muscle

Absorption is more rapid due to blood supply

Incorrect injection techniques may damage blood vessels and nerves

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Intramuscular Injection Sites

Dorsogluteal Ventrogluteal Deltoid Vastus Lateralis

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Intramuscular Administration

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

ml

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Intramuscular Administration

Pull skin away from site to displace tissue

Inject medication Don’t massage

after injection

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Z-Track For solutions irritating to the tissues

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Intravenous Administration (IV) 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

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Intravenous Administration (continued) Advantages:

Client comfort Easy access for nurses

Disadvantages: Time and skill required for venapuncture Difficulty in maintaining an IV line Greater potential for adverse reactions Possible complications of IV therapy

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Intravenous Administration (continued)

Assess IV insertion site: Pain Redness Bleeding Swelling Dressing dry and intact

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Nursing Care with IV Medications 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

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Nursing Care (continued)

When discontinuing IV catheter on a client on anticoagulants, prolonged pressure may be required

Document as per policy

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Intravenous Piggyback (IVPB) 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

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Intermittent IV Therapy

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

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Intravenous Push (IVP) Administration The medication is pushed into the port

by the nurse Before pushing, the nurse must know:

If the medication is compatible with the existing IV fluid

The rate that the push should be given usually in minutes

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Intravenous Administration - Equipment Pumps

Deliver in ml/hour; most pumps deliver to the tenths place (ex: 85.5 ml/hour)

Check IV site before connecting to pump Set rate according to physician’s order Check for kinks or obstructions

frequently

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Central Lines

Terminate in the jugular vein, subclavian vein, brachial vein or even into the right atrium

Strict sterile technique must be followed when accessing these Sterile gloves, masks

Peripheral intravenous infusion catheter (PICC)

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Calculating Dosages

Practice the following:

Dose on hand = 250mgQuantity on hand: 1 tablet = 250mgDesired dose (dose ordered) = 500mg?? = # of tablets required

And the answer is….

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Calculating Dosages (continued)

250 = 500 (cross multiply and divide)

1 x

500/250 = 2

The answer is 2 tablets

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Calculating Dosages (continued) Practice the following (requires

conversion):

Dose on hand = 250mgQuantity on hand: 1 capsule = 250mgDesired dose (dose ordered) = 0.5gm?? = # of tablets required

And the answer is….

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Calculating Dosages (continued) Convert 0.5gm to mg. 1 gm = 1000mg

so 0.5 gm = 500mg 250 = 500 (cross multiply and

divide) 1 x

500/250 = 2

The answer is 2 tablets

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Calculating Dosages (continued) Practice the following (units):

Dose on hand = 10,000 unitsQuantity on hand: 10,000 units per 1 mlDesired dose (dose ordered) = 5000 units?? = # of ml required

And the answer is….

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Calculating Dosages (continued) 5,000 units = x (cross multiply

and divide) 10,000 units = 1

5000/10,000 = ½ or 0.5

The answer is 0.5 ml

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Calculating Dosages (continued) Practice the following (dose based on

weight):

Medication order: Lovenox 1mg/kg BIDDose/quantity on hand = 80mg/mlPatient’s weight = 154 pounds?? = # of ml required

And the answer is….

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Calculating Dosages (continued) Convert pounds to kilograms (2.2 lbs =

1 kg) 154/2.2 = 70kg

1mg x 70kg = 70mg

Cross multiply and divide: 80mg = 70mg 70/80 = 0.8 1ml = x The answer is 0.8 ml

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Photo Acknowledgement:All unmarked photos and clip art contained in this module

were obtained from the 2003 Microsoft Office Clip Art

Gallery.