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Medication Administration 1 Legal & Ethical Role of the RN in Drug Administration • Because of the risks involved in drug administration patients have the right to: • be informed of the name, purpose, action & potential side effects of drugs • refuse a medication regardless of the consequences • Forcing a competent adult to take a medicine may be considered battery • Battery is the unlawful use of force 2 Medication Labels Medication labels must have: • Patient name • Medication name (generic) • Route • Dosage • Frequency • Prescriber’s Name • Pharmacy Contact Information 3 Black Box Warnings • A way of flagging important safety information • It is the most serious medication warning required by the FDA • Used when the medication can cause serious undesirable effects compared to the potential benefit from the drug • Indicates need for extra precautions A Black Box warning does not indicate that drug is too dangerous to use – just that maximum precaution must be taken 4 RN Responsibilities • To advocate for patients • To be knowledgeable about any medications they administer • Including necessary patient assessments & how to administer the medication. • To clarify any ambiguous, incomplete or contradictory order • To delegate medication administration only to providers with the training and legal status to give those drugs 5 RN Responsibilities • To monitor for therapeutic and adverse effects • To withhold medications whenever patient safety is in question • When in doubt, double check! • Refuse to administer medications if you are unsure of anything (medication, dose, route) • To accurately document medication administration • To report all medication errors and near misses per institution protocol and to national databases as indicated. 6 Medication Administration 7 Local and Systemic Effects • Local effects: •Exert their effect at the site of administration •Examples: lidocaine to numb the skin before sutures, antifungal ointments • Systemic effects: •Absorbed and distributed throughout the body systems. • Drugs administered enterally are absorbed from the stomach and small intestine. • Drugs administered parenterally (and some topical drugs) are transported directly into the blood. 8 Enteral Route and Forms • The enteral route involves using the GI tract for the administration and absorption of drugs. • Variety of forms • The oral route of administration is the most common enteral route. • Some oral drugs are given for their local effect in the GI tract. • Most drugs are given to achieve a systemic effect. 9 Parenteral Route • Intramuscular administration – Involves injecting drugs into certain muscles – The onset of action with intramuscular injections is faster than with oral administration. – The most common sites for IM injection are the ventrogluteal, deltoid rectus femoris, and vastus lateralis muscles. – Many experts and nursing fundamental texts no longer recommend using the dorsogluteal site due to possible sciatic nerve damage. 10 Parenteral Route (cont.) • Subcutaneous administration – Drugs are administered under the skin into fat and connective tissue. – These drugs must be highly soluble, low volume, and nonirritating. 11 Parenteral Route (cont.) • Intravenous administration – The drug is administered directly into the bloodstream. – IV administration ensures prompt, sometimes immediate, onset of action. – Eliminates the uncertainty associated with varied absorption rates from other routes – The IV route is also, however, one of the most dangerous routes! 12 Other Parenteral Delivery Routes • Intradermal – Injections are made into the dermis just below the epidermis. – This technique is used primarily for local anesthesia and for sensitivity tests, such as allergy and tuberculin tests. • Intra-articular: Injecting a drug into a joint • Intra-arterial: A catheter inserted into an artery leading directly to the targeted treatment area • Intrathecal: A drug is delivered into the cerebrospinal fluid, e.g. an epidural in childbirth 13 Nursing Management in Parenteral Drug Administration • This route allows drugs to be distributed directly to the vascular system. • The parenteral route avoids erratic absorption. • Parenteral routes may also be necessary because of the GI irritant nature of the drug. • Drugs administered by the parenteral route have a faster onset of action than those administered orally or topically. 14 Assessment of Patient Variables • Health status: A parenteral route may be chosen because the patient cannot tolerate oral drugs. • Life span and gender: – Infants have small muscle mass. – Elderly people have decreased muscle mass overall and decreased tissue elasticity. • Lifestyle, diet, and habits: Parenteral forms of drugs are more expensive than oral forms. • Environment: The parenteral route requires increased patient teaching. 15 Topical Route • Apply the drug preparations to the skin or mucous membranes, including the eyes, ears, nose, rectum, vagina, and lungs. • The primary advantage is that the drugs usually act locally. • A disadvantage of topical drugs is that most are intended for only one specific site. • Many different drugs can be given topically. 16 Topical Drug Forms • The most common and widely used topical agents applied to the skin include lotions, creams, liquids, ointments, and emollients. • Transcutaneous or transdermal drug delivery systems deliver a specific amount of a drug. • Drugs administered to the eye take the form of drops or ointments. 17 Topical Drug Forms (cont.) • Drugs administered through the rectum are either in suppositories or in ointments. • Drugs administered into the vagina are in the form of suppositories, creams, foams, liquids, or tablets. • Drugs given into the nose are in liquid sprays, drops, or aerosol preparations. • Inhalers are used for respiratory conditions. 18 Nursing Management in Topical Drug Administration • Assessment of relevant core patient variables – Assessment involves inspecting the skin for integrity. • Planning and intervention • The nurse should wear gloves. • Sterile technique is used when the skin is broken. • In the event of an adverse effect, remove the medication. 19 Question Which of the following routes has the fastest rate of absorption? – A. Oral – B. Sublingual – C. Intramuscular – D. Intravenous 20 Question Which of the following routes has the fastest rate of absorption? – A. Oral – B. Sublingual – C. Intramuscular – D. Intravenous 21 Question It is acceptable for a nurse to crush sustained-release medication to be administered via an NG tube. – A. True – B. False 22 Question It is acceptable for a nurse to crush sustained-release medication to be administered via an NG tube. – A. True – B. False The purpose of a sustained-release medication is to work over an extended period of time. If the medication is crushed when administered, it will not be absorbed slowly in the body. 23 Question Which of the following is a disadvantage of giving a medication by the IV route? – A. Immediate effect of the medication – B. Allows administration of a large volume of drug – C. Can cause local tissue irritation – D. Circumvents impaired circulation 24 Question Which of the following is a disadvantage of giving a medication by the IV route? – A. Immediate effect of the medication – B. Allows administration of a large volume of drug – C. Can cause local tissue irritation – D. Circumvents impaired circulation 25 Adverse Effects and Drug Interactions 26 Adverse Effects An adverse effect of drug therapy is a usually an undesirable effect. • It may occur even with normal drug dosing. • An adverse effect may result from – Too much of a therapeutic effect – Other pharmacodynamic effects of the drug 27 Adverse Effects • Every drug can produce adverse effects. • Serious adverse effects lead to the withdrawal of a small number of drugs from the market every year. • It is important for nurses and other health care professionals to be alert for adverse effects from drug therapy. • Serious adverse reactions to a drug, especially a newly approved drug, should be reported to a national database. 28 MedWatch • Report serious adverse medication events to the national database: • Death or potential fatality • Significant disability • Prolonged hospitalization • Birth defect • Requires intervention to prevent permanent damage • http://www.fda.gov/Safety/MedWatch 29 Drug Interactions • A drug interaction occurs when two drugs or a drug and another element have an effect on each other. • This interaction may – Increase or decrease the therapeutic effect of the drugs – Create a new effect – Increase the incidence of an adverse effect 30 Risks for Drug Interactions • Immature physiologic processes • Chronic disease or aging organ systems • Malnutrition, recent weight changes • Alcohol abuse • Certain modified diets (high fat) • Multiple drugs, Rx, or OTC use • Drugs instilled into a feeding tube 31 Allergic and Idiosyncratic Responses • An allergic response is an immune system response. • The antigen–antibody system responds when the drug is taken again. • Symptoms may become more severe each time the drug is introduced into the body. • The most serious allergic response is called anaphylaxis. • Idiosyncratic responses are unusual and in fact may be the opposite of what is anticipated. •Example: agitation with a sedative drug 32 Toxicities • Neurotoxicity (central nervous system) – Drowsiness, auditory and visual disturbances, and seizures • Hepatotoxicity (liver) – Manifestations include hepatitis, jaundice, elevated liver enzyme levels, and fatty infiltration of the liver. • Nephrotoxicity (kidneys) – Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances 33 Toxicities (cont.) • Ototoxicity (eighth cranial nerve) – Tinnitus, hearing loss, light-headedness, vertigo, nausea, and vomiting • Cardiotoxicity (heart) – Irregularities in conduction, heart failure, and damage to the myocardium • Immunotoxicity (immune system) – Immunosuppression, increased incidence of bacterial, viral, and parasitic infections 34 Drug Interactions • Drug interactions occur when one drug is affected in some way by another drug. • Drug interactions may be beneficial. • Negative effects from drug interactions are those that decrease the therapeutic effect. • Drug interactions may take place in any phase of pharmacokinetics. • Drug interactions can also change the pharmacodynamics of a drug. 35 Drug Interactions Affecting Absorption Drug absorption can be decreased because of drug interactions. • If a drug binds with another substance in the GI tract, less of the drug is available to be absorbed. • This binding of a drug is termed chelation. Drug absorption may also be increased as a result of a drug interaction or the presence of food in the GI tract. • The exact extent of changes in drug absorption caused by drug interactions is often difficult to predict. 36 Drug Interactions Affecting Distribution Distribution is affected by three types of drug interactions. • Circulatory system performance • Competitive protein binding. • Drug alteration due to extracellular pH 37 Drug Interactions Affecting Metabolism Probably the most important and common drug interaction is one that alters the metabolism of a drug. • Drugs that induce a hepatic enzyme increase the amount of that enzyme in the liver. Drugs are then metabolized more quickly • If two drugs that affect the cytochrome P-450 system must be administered to a patient together, the dose of one of the drugs may have to be adjusted. 38 Drug Interactions Affecting Excretion • Drugs can alter renal filtration, renal reabsorption, or renal secretion. • Glomerular filtration is dependent on blood flow to the kidney. • Drugs that decrease cardiac output decrease the amount of circulating blood that is sent to the kidneys. • Renal reabsorption of a drug is dependent on whether a drug is ionized. 39 Additive Effect • An additive effect occurs when two or more “like” drugs are combined. – Example: Codeine with acetaminophen work together to produce better pain control. • An additive effect may be intentional or may unintentionally cause harm. – Example: Alcohol and anxiety medications can both cause sedation, taken together they greatly increase the risk of sedation even to the possibility of death. 40 Synergistic Effect • A synergistic effect occurs when two or more “unlike” drugs are used together to produce a combined effect. • Example: – A beneficial synergistic effect occurs when two different types of antibiotics that work in very different ways are combined, such as penicillin G and an aminoglycoside antibiotic. 41 Potentiated Effect • Potentiation is an interaction in which the effect of only one of the two drugs is increased. • In other words, a drug that has a mild effect enhances the effect of a second drug. – Example: Hydroxyzine (Vistaril, Atarax) increases the effect of morphine. – The addition of fluoxetine (Prozac) to the antihypertensive lisinopril (Zestril) can decrease the blood pressure after steady state of the fluoxetine is reached. 42 Antagonistic Effect • An antagonistic drug interaction is the opposite of a synergistic effect. • It results in a therapeutic effect that is less than the effect of either drug alone because the second drug either diminishes or cancels the effects of the first drug. • Antagonistic interactions can also occur at receptor sites. – Example: Protamine reverses the action of heparin. 43 Drug Incompatibilities • Chemical incompatibilities – Chemical incompatibilities between drugs change both the drug’s structure and its pharmacologic properties. • Physical incompatibilities – Physical incompatibilities occur when two drugs are mixed together. – The mixture results in the formation of a precipitate. 44 Assessment of Patient Variables • Health status – Multiple medical conditions may increase the risk of adverse effects from drug therapy. • Life span and gender – Age can greatly increase the risk of adverse effects from drug therapy. The very young and the very old are most at-risk Older adults are more likely to be receiving polypharmacy for multiple chronic illnesses. 45 Assessment of Patient Variables (cont.) • Culture and inherited traits – Researchers are beginning to study responses to drug therapy that are genetically determined in various ethnic and racial populations. – These responses may place the patient at greater risk than the rest of the global population for adverse effects or drug interactions. – Use of herbals and OTC medications increase risk 46 Herbal Supplement Use • Compared to prescription medications, herbal supplements are • Relatively low in cost • Easy to obtain. • 70% of patients neglect to tell their healthcare provider that they are taking an herbal supplement. • “Natural” does not always mean “safe.” • They may contain unknown ingredients and may interact with medication 47 Reasons Patients Don’t Tell Providers about Supplements • Do not feel the supplements are medicines. • Feel that because the supplements are natural, they must be safe. • Are not asked if they are taking any supplements by their provider. • Fear of disapproval 48 Regulation of Dietary Supplements • Food and Drug Administration (FDA) • Regulates food, OTC, and Rx drugs • Manufacturer must prove safety before marketing the product • DSHEA (Dietary Supplement Health Education Act of 1994) • Must have truth in advertising and not overtly claim to treat diseases • FDA must prove product unsafe or labeled in a misleading manner after product is marketed 49 Areas of Concern with Supplements • Lack of standardization • Potency varies with • Part of plant used • Growing, processing, storage conditions • Research cannot prove worth if components uncertain • Many instances of incorrect ingredients • Contamination with dangerous substances • Pharmaceuticals • Heavy metals (mercury/lead) 50 More Concerns • Interactions with other drugs • Increased risk if botanical intake not disclosed to health-care provider • Anesthesiologists advise discontinuing many herbal products 2 to 3 weeks before surgery • Difficulty obtaining reliable information • Consider the source – often seller of product • Scientific information is scarce 51 Nursing Implications • Ask about all treatments a person uses in a nonjudgmental way. Avoid using only the word “medicine” • Consider the following information for all supplements a patient is using: • What are the supplements therapeutic effects? • What are the supplement’s adverse reactions? • Are there pregnancy or breastfeeding consideration? • What are the adverse interactions with other supplements or medications • Does bioavailability very greatly with the supplement? 52 Overview of Common Herbs & Supplements from National Center for Complementary and Alternative Medicine (NCCAM) • St John’s work • Ginko biloba • Garlic • Ginger • Glucosaminechondroitin • Fish oils • Echinacea • Valerian • Kava • Ephedra 53 St John’s Wort • Systematic review shows St. John's Wort appears to be superior to placebo and effective as an antidepressant with fewer side effects • Findings from studies in German-speaking countries were favorable. • Interacts with up to 60% of conventional drugs in one of three ways: • Induces of cytochrome P450-accelerates metabolism of some drugs (including birth control) • Induction of P-glycoprotein-accelerates elimination of some drugs (reduces digoxin levels) • Intensification of serotonin when used with SSRI antidepressants 54 Ginkgo Biloba • Promoted to improve cerebral circulation and enhance mental functioning • 8 -year Ginkgo Evaluation of Memory study • Ineffective in reducing the development of dementia and Alzheimer's disease in older people. • Did not prevent heart attack, stroke, or death in a group of older adults. • May reduce the risk of developing peripheral arterial disease • BUT European studies show is slows memory loss • Ginkgo may increase bleeding when combined with medications with anticoagulant properties like aspirin 55 Garlic • Used to treat heart disease & prevent colon cancer • Some studies suggest lowers cholesterol • Preliminary research suggests may slow the development of atherosclerosis • Evidence is mixed on whether taking garlic can slightly lower blood pressure. • Warnings: • Garlic supplements (not food) have been found to interfere with the effectiveness the HIV drug saquinavir • Blood thinning properties similar to aspirin discontinue one week prior to surgery 56 Ginger • Studies suggest that the short-term use of ginger can safely relieve pregnancy-related nausea and vomiting. • Studies are mixed on whether ginger is effective for nausea caused by motion, chemotherapy, or surgery. • Few side effects are linked to ginger when it is taken in small doses such as tea or eating in cookies. • High doses may interfere with anticoagulation therapy 57 Glucosamine-Chondroitin • Used to treat joint pain. First used in high-performance race horses. GAIT Study Two-Year Results: June 2010 • Patients who took the supplements (alone or in combination) for knee osteoarthritis pain had outcomes similar to those experienced by patients who took celecoxib (Celebrex) or placebo pills. • Increases risk of bleeding when taken with warfarin (Coumadin) 58 Fish Oils (Omega3 Fatty Acids) • Most popular supplement on market. • Some name brand fish oils are FDA regulated-Lovaza • Effective For lowering triglycerides • Decreases inflammation • Likely effective for preventing heart disease and heart attacks • Possibly effective for • High blood pressure and Stroke, Rheumatoid arthritis and other autoimmune disorders, Menstrual pain, Weight loss, ADHD, Mood disorders, Kidney disease, Miscarriage, Osteoporosis, Age related eye disorders • Mixed studies on if increased risk of prostate cancer • Can increase risk of bleeding with anticoagulation therapy 59 Echinacea • Used to bolster the immune system with the onset of a common cold or upper respiratory infection. • Large study showed Echinacea has small trends in the direction of a benefit from: • an average half-day reduction in duration of symptoms and, • approximate 10 percent decrease in severity • Concluded 1275 mg Echinacea did significantly change the course of the common cold. • People with asthma or ragweed allergy may be more likely to have an allergic reaction while taking Echinacea 60 Valerian • Long history of use before development of sedating meds • May helpful for insomnia, but there is not enough evidence yet from well-designed studies • Not enough scientific evidence to determine whether valerian works for anxiety, depression, menopause or Parkinson’s disease. • Studies suggest that valerian is generally safe to use for short periods of time (for example, 4 to 6 weeks). Long term safety has not been established • • May potentiate other CNS depressants, risk for delayed awaking from anesthesia 61 Kava • Used to relieve anxiety, promote sleep, and relax muscles; natural alternative to benzodiazepines • Some suggests kava may be beneficial for the management of anxiety. • The U.S. Food and Drug Administration (FDA) has issued a warning that using kava supplements has been linked to a risk of severe liver damage. • Potentiates alcohol and barbiturates • Avoid driving and operating heavy machinery 62 The Banned: Ephedra- Ma Huang • Used for weight loss and treatment of asthma • Between 1995 and 1997, the FDA received more than 900 reports of possible ephedra toxicity. • Serious adverse events such as stroke, heart attack, and sudden death were reported in 37 cases. • In 2004, the FDA banned the U.S. sale of dietary supplements containing ephedra • The ban does not apply to traditional Chinese herbal remedies or to products like herbal teas regulated as conventional foods. 63 Greatest Risk for Drug-Dietary Supplement Interactions • Children • The elderly • People with chronic diseases or impaired organ function • Persons taking many medications • Individuals with genetic variants in drug metabolism 64 Providing Patient and Family Education • Inform the patient and family about adverse effects and drug interactions. • Initial instruction includes teaching the patient how to minimize the occurrence of these effects. • Teach the patient which effects to expect, which to report to the prescriber, and which require immediate medical attention. 65 66