Download Medication Administration

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
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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
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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.
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Medication
Administration
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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.
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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.
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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)
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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
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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
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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.
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