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Medication Administration Presented by Denise Auttonberry, Ph.D., MSN, RN Outline developed by Glenda Moore, MSN, RN A.D.Nursing Faculty Regulation of Medicines 1906 – Pure Food and Drug Act 1914 – Harrison Act 1932 – State Narcotic Act 1970 – Controlled Substances Act US Food and Drug Administration Pharmacology Study or science of drugs Common Terms, Symbols and Abbreviations Review from study sheet. Small groups. JCAHO DO NOT USE LIST Examples U, IU – Unit, International Unit QD, QOD – (Write it out) daily, every day, every other day. Trailing Zero – 1.2500 MS, MSO4, MgSO4 – morphine, sulfate morphine sulfate, magnesium Who can order medications? A licensed practitioner – always be familiar with the state practice act and agency policy. Physician Nurse – MD or DO Practitioner – NP Physician Dentist Assistant - PA – DDS or DMD Podiatrist - DPM Who can dispense medications? licensed pharmacist – R.Ph. or Pharm.D. Who can give medications? Registered Nurse – RN Licensed Practical Nurse – LPN Respiratory Therapist – CRT, RRT Paramedic – prehospital only Who regulates nursing practice? Professional Regulation Standards Accreditation Certification Legal Regulation The Board of Nursing - State Agency Nurse Practice Act Scope of Practice Voted by State Legislature Resources for Medication Administration Nursing & Pharmacology Textbooks Nursing Drug Guides Preprinted Drug Cards Physician Desk Reference (PDR) Hospital Formulary Pharmacy Internet Resources Nursing Responsibilities for Administering Drugs Assessing the client and understanding the need for medication. Ensuring the rights of medication administration. Preparing the medication to be administered using accurate dosage calculation. Nursing Responsibilities for Administering Drugs – con’t Administering medication and documenting it was given. Monitoring client response. Educating client regarding medication regimen. Safety Considerations in Medication Administration Knowledge about the medication. The five/six rights. Three checks. Safe dosage. Safe environment. Knowledge Needed to Administer Drugs Safely Drug name, preparations, and classifications. Mode of action and purpose of medication. Side effects and contraindications for medication. Antagonist of medication. Knowledge Needed to Administer Drugs Safely – con’t Safe dosage range for medication. Interactions with other medications. Precautions to take prior to medication. Proper administration technique. What are the five rights? Right patient Right medication Right dosage Right route Right time Right documentation Right reason med is given What are the six rights? Who? What? When? Where? How much? Write Why? it down Client Rights Remember – Clients always have the Right to Refuse. What are the three checks? Container or unit dose package compared with MAR Compare with MAR immediately before removing from package or multi-dose container. Returning container to shelf or before giving the unit dose to the client compared with MAR. How do we know the dosage ordered is safe? Knowledge of the drug Accurate calculations To maintain safe patient dosage Monitor blood levels Safe dosage levels May be ordered as: Loading dose Maintenance dose Example – blood thinners, some antibiotics What is a safe environment? Well lighted Quiet, minimal distractions Work alone when possible, except as students NEVER leave meds unattended. Legal/Ethical Factors Nursing Responsibility Documentation Physician’s Prescriptions Medication Errors Agency Policies Narcotic/Control Drugs Nursing Responsibility To properly and correctly prepare, administer, document medication administration, observation, and teaching of client. Nursing Responsibility PATIENT EDUCATION IS A MAJOR NURSING INTERVENTION Medical Record Documentation MAR – Medication Administration Record Legal document Chart each dose of medication ASAP Never chart ahead of time CMAR – computerized User ID/password Medical Record Documentation Intentional or inadvertently omitted drugs Refused drugs Medication errors Proper Signature on MAR Agency will have specific policy Signing when medications are administered Signing when medications are held Where to put signature and corresponding initials Approved HCC signature Signature A. Showers, Hinds NS Initials AS CAREFUL DOCUMENTATION --THE KEY TO COMPETENT PRACTICE Military/Computer Time 24 hour clock Midnight – 12:00 AM = 2400 (0000) Noon – 12:00 PM = 1200 Convert AM time: remove colon, place zero in front 9:15 AM =0915 Convert PM time: remove colon, add 1200 5:30 PM - 1730 Physician’s Prescriptions Who can?? CPOE – Computer Prescriber Order Entry Written Verbal/telephone Never students Agency Policy Executing HCP Prescriptions Nurse is legally liable for administering medications. Nurse Practice Act Agency/institution policy Get written orders when possible Executing HCP Prescriptions Double check any order that client questions Question any order that is: Ambiguous Contraindicated by- Normal practice Client’s present condition Types of Medication Orders Standing order PRN order One-time order Stat order Telephone/verbal order Stop order Automatic stop order Parts of the Medication Order Client’s Name Date and time order written Drug name Dosage Route Frequency Signature of person writing order Medication Supply System Stock supply Individual supply Medication cart Computerized/automated medication system Bar coded medication cart Computerized Medication Dispensing System Drugs from Home What can we do? Self administered medications Use of meds from home Must have order for self administration and to have meds at bedside Document given by client Systems of Measurement Metric – meter (linear), liter (volume), gram (weight) Apothecary – les convenient and concise; basic unit or weight is grain Household – least acurate system; teaspoons, tablespoons, teacup, glasses used Conversions Conversions between Systems – See Calculate With Confidence Conversions Medications not usually ordered in household measurements (Home oral med for children may be ordered in tsp. Must use measuring device with that med) Some still may be ordered in apothecary— grains Acetaminophen & aspirin Morphine, Nitroglycerin, & Phenobarbital Signs & Symptoms of Drug Allergy Rash Uticaria Pain Fever Diarhea Nausea/Vomiting Angioedema Anaphylactic reaction- involves 2 or more body systems Anaphylactic reactions Local Urticaria (hives) Edema Warmth Erythema Systemic Urticaria Angioedema flushing, Wheezing Dyspnea Increased mucous production N&V Feeling of generalized anxiety Anaphylactic reaction Local reaction Anaphylactic reaction systemic Types of Medication Errors Inappropriate prescribing of the drug Extra, omitted, or wrong doses Wrong patient Wrong route or rate Failure to give drug within prescribed time Incorrect preparation of a drug Improper technique when administering drug Giving a drug that has deteriorated Narcotic/Control Drugs Controlled /substance Act Schedule I-V C-I – no aceptable medical use (heroin) C-II – high abuse potential (morphine) C-III – intermediate abuse potential (hydrocodone, valium) C-IV – less abuse potential (benzodiazepines) C-V – limited abuse potential, recorded as transaction (cough syrup with codeine) Which agency has control? Which governmental Agency has jurisdiction? Drug Enforcement Agency Medication Administration Nursing Process Assessment Diagnosis Planning Implementation Evaluation Assessment Health history Previous and current drug use Ask about OTC/herbal preparations Schedule Response Attitude Compliance Storage Always assess before, during, and after administration Planning - Nursing Diagnosis Varies with abnormal data found/problems identified Planning- goal-outcome for that diagnosis Interventions and rationales Evaluate the stated outcome Implementation Utilizing the “6 Rights” Preparing Right drug Right reason Right dose and preparation Before Right client (2 methods of ID—not room number according to The Joint Commission National Patient Safety Goals) Right medication Right dose, route, time After Right documentation Right response Implementation Stay with client Give each drug separately Never leave medications Document promptly Implementation Oral medications- most common; convenient and comfortable for client Many forms To crush or not to crush-that is the question. “Cheeking” Special techniques Special considerations Children Older adults Enteral tubes Administering Eye Drops into Conjunctival Sac Instilling Ear Drops – Adults Pulling Pinna up and Back Instilling Ear Drops – Child Pulling Pinna down and Back Instilling Nose Drops/sprays Used to treat allergies, sinus infections, and nasal congestion Medications with a systemic affect may also be instilled in the nose Medical asepsis should be observed when instilling drops Transdermal patch Remove old patch, fold in half (adhesive sides together and discard per agency policy Assess skin Clean with soap and water Wear gloves (don before opening/handling patch) Apply patch: Remove patch from packaging Write date, time, (initials) on patch Apply to site, use palm of hand to press firmly for 10 seconds Certain medications are to be applied to specific sites. Administering a Vaginal Medication Creams, foams, tablets, and suppositories melted by body heat can be applied intravaginally May use a narrow tubular applicator with an attached plunger Administration should be timed to allow patient to sit down afterward to retain medicine May need to lubricate tablet or suppository to ease insertion Administering a Vaginal Medication Administering a Rectal Suppository Must be placed past the internal anal sphincter and against rectal mucosa Positioning of client? Used primarily for local action Laxatives Fecal softeners Systemic effects also achieved Lubricate suppositories to ease insertion Inserting the Suppository Round End First Along the Rectal Wall Implementation Pulmonary medications MDI (metered dose inhaler) With or without spacer Small-volume nebulizer DPI (dry powder inhaler) Inhalers Implementation Medications via a gastric tube How would you administer through PEG tube? What if NG tube is to Low Continuous Suction? Implementation Medication Administration Remember Reconcile MAR with orders Prepare medication Administer medication Document administration Always assess TEACHING Educate about General info—what How and when to administer Expected side effects and adverse effects When to follow up when to call/report Special instructions Patient Teaching Review techniques of medication administration Remind client to take the medication as prescribed for as long as prescribed Instruct client not to alter dosages without consulting physician Caution client not to share medications WHO DO WE TEACH? Client Family Caregivers How do we teach? Teaching & Learning Chapter 22 in Taylor, Fundamentals. Teaching Acronym T – tune into the patient E – edit patient information A – act on every teaching moment C – clarify often H – honor the patient as partner in the education process Client Teaching First determine what the client knows Identify learning needs Identify ethnic, socioeconomic, and physiological factors that influence medication usage Explain &/or demonstrate how to take the medication Ask for a return demonstration Evaluation Effectiveness of drug Clinical observation Subjective data Objective data Drug levels Monitoring devices Pharmacodynamics Therapeutic effect Mechanism of action Receptor e.g., Beta blockers Enzyme interactions interactions e.g., ACE inhibitors Nonselective interactions Pharmacokinetics Absorption—drug is transferred from site of entry into bloodstream Distribution—drug is distributed throughout the body Metabolism—drug is broken down into an inactive form Excretion—drug is excreted from the body Drug Classifications Can be classified by Body system Symptoms relieved Clinical indication Davis’s Drug Guide for Nurses. Philadelphia: F.A. Davis Company. 14th edition. Davis Drug Guide Quick References Useful tables Summaries of major drug classifications Drug Information You MUST know Name of drug Classification Expected therapeutic effect (action) Reason medication given to client Dosage, route, time of administration Common Side Effects Contraindications Contingencies-common nursing actions Expected therapeutic outcome Patient education needs