Download Chapter 35: Medication Administration

Chapter 35: Medication
Administration
Bonnie M. Wivell, MS, RN, CNS
Introduction
• Medication is a substance used in the
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Diagnosis
Treatment
Cure
Relief
Prevention of health alterations
• The nurse is responsible for the following in
regard to medications:
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Preparation
Administration
Teaching
Evaluating response
Medication Legislation and
Standards
• The role of the U.S. government in regulation of
the pharmaceutical industry is to protect the
health of the people by ensuring that
medications are safe and effective.
• First law was passed in 1906
– Pure Food and Drug Act: requires all meds to be free
of impure products
• Other federal medication laws
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Control medication sales and distribution
Medical testing
Naming and labeling
Regulate controlled substances
Medication Legislation and
Standards Cont’d.
• FDA = enforces laws, and ensures all meds on
the market undergo vigorous testing before
being sold to the public
• MedWatch program = initiated in 1993 by FDA; a
voluntary program that encourages nurses and
other health care professions to report when a
medication, product, or medical event causes
serious harm to a client
• State laws control substances not regulated by
the federal government.
• Local government regulates the use of alcohol
and tobacco
Medication Legislation and
Standards Cont’d.
• An institution is concerned primarily with
preventing poor health outcomes resulting from
medication use
• Medication Regulations and Nursing Practice
are governed by individual state Nurse Practice
Acts (NPAs)
• NPAs have the most influence over nursing
practice by defining the scope of a nurse’s
professional functions and responsibilities
• NPAs are broad in scope and nature so as not to
limit the nurse’s functional ability
• Health care agencies interpret the NPAs
Controlled Substances
• Controlled substances
(AKA narcotics) are
carefully controlled
through federal and state
guidelines.
• Violation of the Controlled
Substances Act is
punishable by fines,
imprisonment, and loss of
nurse licensure.
• See Box 35-1
Patient Safety
• Patient Safety
• To err is Human
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Clinical Effectiveness of Safe Practices
Intervention
Results
Physician computer order entry
81% reduction of medication
errors
Pharmacist rounding with team
66% reduction of preventable
adverse drug events; 78%
reduction of preventable adverse
drug events
Rapid response teams
Cardiac arrests decreased by 15%
Team training in labor and delivery 50% reduction in adverse
outcomes in preterm deliveries
Reconciling medication practices
upon hospital discharge
90% reduction in medication errors
Ventilator bundle protocol
Ventilator-associated pneumonias
decreased by 62%
Pharmacological Concepts
• Drug Names
– Generic: becomes the official name listed in
publications and is the name generally used
throughout the drug’s use
– Chemical: chemicals that make up drug
– Brand/Trade: the name under which a manufacturer
markets a med; usually short and easy to remember
• Many companies produce the same med so
similarities in trade names are often confusing
• Example:
– Brand: Hydrochlorothiazide
– Trade: Esidrix and HydroDiuril
Pharmacological Concepts Cont’d.
• Classification
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The effect of the medication on a body system
The symptoms the medication relieves
The medication’s desired effect
Some medications are part of more than one class
• Medication Forms
– The form of the medication determines its route of
administration
– The composition of a medication enhances its
absorption and metabolism
– Many meds come in several forms: Tablets, Capsules,
Elixirs, Suppositories
Pharmacokinetics
• Pharmacokinetics = the study of how
meds enter the body, reach their site of
action, metabolize, and exit the body
• Absorption = passage of med into blood
– Route of administration
– Ability of med to dissolve
– Blood flow to site of administration
– BSA
– Lipid solubility of a med
Distribution
• After absorption, distribution occurs within the body
to tissues, organs, and to specific sites of action via
blood stream.
• Distribution depends on:
– Circulation: limited blood flow can inhibit distribution
– Membrane permeability
• Blood brain barrier and Placenta
– Protein Binding: most meds bind to albumin to some
extent
• Meds bound to proteins can’t do what they are supposed to
• “Free” or unbound medication is the active form of the med
• Decreased albumin due to disease process → more active
medication → med toxicity
Metabolism
• Medications are metabolized into a less
potent or an inactive form.
• Biotransformation occurs under the
influence of enzymes that detoxify,
degrade, and remove active chemicals.
• Most biotransformation occurs in the liver
• Other sites for metabolism: lungs,
kidneys, blood, intestines
Excretion
• Medications are excreted through:
– Kidney
– Liver
– Bowel
– Lungs
– Exocrine glands
Types of Medication Action
Therapeutic effect:
Side effect:
Expected or predictable
Predictable and often
unavoidable
Adverse effect:
Toxic effect:
Unintended, undesirable,
and often unpredictable
severe response
Medication
accumulates in the
blood stream
Idiosyncratic reaction:
Allergic reaction:
Over- or under-reaction to
a medication
Unpredictable response
to a medication
Medication Interactions
• Occur when one medication modifies the
action of another
• A synergistic effect occurs when the
combined effect of two medications is
greater than the effect of the medications
given separately.
– Can be beneficial: Tylenol and Codeine
– ETOH and antihistimines, antidepressants, or
narcotics (all CNS depressants)
– HTN may be treated with diuretic and vasodilator
Medication Dose Responses
Serum half-life:
Onset:
Time for serum medication
concentration to be halved
Time it takes for a
medication to produce a
response
Peak:
Trough:
Time at which a medication
reaches its highest effective
concentration
Time at which drug is at its
lowest amount in the serum
Duration:
Plateau:
Time medication takes to
produce a response
Blood serum concentration is
reached and maintained
Routes of Administration
Oral
Parenteral
Swallow, Sublingual, Buccal ID, Sub-Q, IM, IV
Other
Topical
Epidural, Intrathecal,
Intraosseous,
Intraperitoneal, Intrapleural,
Intraarterial
Skin
Transdermal patch
Instillation or irrigation
Inhalation
Intraocular
Nasal passages, oral
passage, ET or trach
Insertion of disk containing
med; drops
Effects of Nutrition on Drugs
Grapefruit
Vitamin K
Can cause toxicity when taken
with cisapride, carbamazepine,
diazepam, verapamil,
amiodarone, lovastatin
Decrease effectiveness of
warfarin
In combination with MAOI meds
Tyramine (found in
(Nardil, Parnate, Marplan)
cheese, beer, dried
sausage, sauerkraut) creates increase in epinephrine
 HA, ↑ P, ↑ BP  death
Milk
Interferes with absorption of
tetracycline antibiotics
Systems of Medication
Measurement
• Requires the ability to compute
medication doses accurately and correctly
• Metric system: organized in units of 10
• Apothecaries: older than metric
• Household system: least accurate
• Solution
Nursing Knowledge Base
• Safe administration is imperative
• Nursing process provides a framework for
medication administration
• Clinical calculations must be handled without
error
– Conversions in and between systems
– Dose calculations
– Pediatric and elderly calculations
– ALWAYS double-check calculation and medication
with a second nurse on high alert meds (insulin,
heparin)
Prescriber’s Role
• Prescriber can be physician, nurse practitioner, or
physician’s assistant.
• Prescribers must document the diagnosis,
condition, or need for each medication.
• Orders can be written, computer generated,
verbal, or by telephone.
• DO NOT use abbreviations on pages 701-703
when documenting med orders or other
information about meds
Types of Orders in Acute Care
Agencies
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Standing or Routine Medication Orders
PRN Orders: as needed
Single (one-time) Orders
STAT Orders: within 15 mins
Now Orders: up to 90 mins to administer
Prescriptions: taken outside the hospital
Communication of Medication Order
• Order is written on client’s chart
– By provider or RN receiving TO or VO
• Order copied to Medication Administration
Record (MAR)
• MAR contains: name, room, bed, drug
name, dose, route, times, allergies
• Video
Components of Medication Orders
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Client’s full name
Date and time that the order is written
Medication name
Dose
Route
Time and frequency of administration
PRN orders must have a reason
Signature
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Medication Administration
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Pharmacist’s role
Distribution system
Medication errors (near miss)
Medication Reconciliation
– Verify
– Clarify
– Reconcile
– Transmit
• Nurse’s role
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The Six Rights of Medication
Administration
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Right medication
Right dose
Right patient
Right route
Right time
Right documentation
Right to refuse
Where Do Drugs Come From in the
Hospital?
• Pyxis/Omnicell
– Machine on the nursing unit where a stock supply of
meds are stored
• Commonly used meds
• Narcotics
• Packaged in the pharmacy and delivered to the
nursing unit
• Unit dose system: drugs are packaged individually
• Liquids can be unit dose or bottles
– Medication in bottles will be measured in Milliliters, teaspoons,
ounces, etc.
Potential Medication Error
Critical Thinking
• Knowledge: understand why you are
giving a med; if you don’t know, look it up
• Experience: skills become more refined
• Attitudes: take adequate time to prepare
and administer
• Standards: ensure safe practice
– 6 Rights
The Nursing Process and Med
Administration
• Assessment
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Medical history
Allergies
Medication data
Diet history
Client’s perceptual or coordination problems
Client’s current condition
Client’s attitude about medication use
Client’s knowledge and understanding of medication
therapy
– Client’s learning needs
Nursing Diagnosis
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Anxiety
Ineffective health maintenance
Health-seeking behaviors
Deficient knowledge (medications)
Noncompliance (medications)
Disturbed visual sensory perception
Impaired swallowing
Effective therapeutic regimen management
Ineffective therapeutic regimen management
Planning
• Minimize distractions or interruptions when
preparing and administering meds
• This will limit errors
• Prioritize care when administering meds
• Collaboration
– Prescriber
– Pharmacist
– Case manager/social worker
Implementation
• Health promotion
– Client and family teaching
• Acute care
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Receiving med orders (write it down and read it back)
Correct transcription and communication of orders
Accurate dose calculation and measurement
Correct administration
Recording med administration
• NEVER chart a med before administering it
• Restorative care: med administration varies
across care settings
Special Considerations
• Infants and children
– Vary in age, weight, surface area and the ability to
absorb, metabolize, and excrete meds
– Lower doses; special calculations
– Alternative forms, such as liquids or elixirs
Psychological prep
• Older adults
– Simplify
– Assess swallowing
– Some have greater sensitivity
• Polypharmacy
Evaluation
• You must monitor a client’s response to
meds on an on-going basis
• The goal of safe and effective med
administration involves the client’s
response to therapy and ability to assume
responsibility for self-care
• You will evaluate the effectiveness of
nursing interventions when you assess
whether the client has met goals/outcomes
• Will cover actual administration and other
issues surrounding administration during
tomorrow’s class
• QUESTIONS?