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1
Module 7
Pharmacology I:Medication Administration
2
Safe Practices in Medication Administration
3
“7 Rights” of Safe Medication Administration
Right Drug Right Dose Right Time Right Route Right Patient Right Reason Right Documentation
4
“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
5
“7 Rights” (continued)
Right Time Follow agency policy
Right Route Follow medication order and knowledge of
appropriate routes for specific drugs
6
“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
7
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)
8
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
9
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!
10
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
11
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?
12
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
13
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
14
Medical-Surgical Asepsis and Medication Administration
Medical Asepsis Handwashing Standard precautions
Surgical Asepsis Use of sterile supplies
15
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.
16
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.)
17
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.
18
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
19
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
20
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)
21
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)
22
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)
23
Schedules of Controlled Substances
See schedules Study Guide 5 Give an example of one drug from each
category
24
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
25
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”
26
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
27
“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
28
Sources for Locating Drug Information Physician’s Desk Reference National Formulary or Hospital
Formulary Pharmacists Drug reference books Pharmacology textbooks Computer-based Indexes
29
Drug Misuse
Drug misuse - Improper use of any medication which leads to acute/chronic toxicity
Drug abuse - Inappropriate intake of a substance
30
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
31
Pharmacokinetics
“What the body does to the drug” Absorption Distribution Metabolism/Biotransformation Excretion
32
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
33
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
34
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
35
4 Factors Affecting Distribution Blood flow Plasma protein binding Amount of the drug Physiological barriers to absorption
Blood-brain-barrier Placental barrier
36
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
37
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
38
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
39
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
40
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.
41
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.
42
Therapeutic Index
Relates to drug’s margin of safety, the ratio of effective dose to a lethal dose
43
Tolerance
Means that a larger dose is needed to bring about the same response
44
Adverse Effect
Any non-therapeutic response to the drug therapy-consequences may be minor or significant
45
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
46
Causes of Drug Interactions
GI absorption Enzyme induction Renal excretion Pharmacodynamic effects Patient care variables
47
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.
48
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
49
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)
50
Nursing Responsibilities for ToxicityAssess for signs of:
Ototoxicity: balance and hearing Nephrotoxicity: I & O, proteinuria GI toxicity: diarrhea Neurotoxicity: drowsiness, seizures
51
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
52
Route of Administration
Depends upon: Drug characteristic Desired responses
Each route has advantages/disadvantages
53
Oral Route
Simple and convenient Relatively inexpensive Can be used by most people Disadvantages:
Slower drug action Irritation of GI tract
54
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
55
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
56
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
57
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
58
Topical Administration
Primarily provides local effect Clean off old medication Apply using appropriate device Special Considerations
Nitroglycerine (NTG) Transdermal Meds
59
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.
60
Vaginal Administration
Cleanse perineum Insert applicator 2 inches Cleanse patient after administration
61
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
62
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
63
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
64
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
65
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
66
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
67
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
68
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
69
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
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
70
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
71
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
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
72
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
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
73
Intramuscular Injection Sites
Dorsogluteal Ventrogluteal Deltoid Vastus Lateralis
Photo Source: Lippincott, Williams & Wilkins, Connection,
Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
74
Intramuscular Administration
Use 21-22g needle Insert at 90 degree angle Max volume 5 ml; usually doses of 1-3
ml
75
Intramuscular Administration
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/smeltzer9e/imagebank.asp
Z-Track For solutions irritating to the tissues
76
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
77
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
78
Intravenous Administration (continued)
Assess IV insertion site: Pain Redness Bleeding Swelling Dressing dry and intact
Photo Source: Lippincott, Williams & Wilkins, Connection, Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
79
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
80
Nursing Care (continued)
When discontinuing IV catheter on a client on anticoagulants, prolonged pressure may be required
Document as per policy
81
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
82
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
83
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
84
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
85
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)
86
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….
87
Calculating Dosages (continued)
250 = 500 (cross multiply and divide)
1 x
500/250 = 2
The answer is 2 tablets
88
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….
89
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
90
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….
91
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
92
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….
93
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
94
Photo Acknowledgement:All unmarked photos and clip art contained in this module
were obtained from the 2003 Microsoft Office Clip Art
Gallery.