Download MEDICATION ADMINISTRATION Chapter 35

MEDICATION
ADMINISTRATION
Chapter 35
5/25/2017
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6 Rights of Medication
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Right Patient
Right Drug
Right Dose
Right Route
Right Time
Right Documentation – if it wasn’t
documented, it wasn’t done
• #7 -THE RIGHT To REFUSE
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The RIGHT Medication
• As the physician prescribed?
• Trade name or generic?
• Does the drug match the MAR (medication
administration record)?
• Is the drug appropriate for the patient?
• Does it make sense?
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The RIGHT Dose
• Does the dose of
medication in your
hand agree with the
dose on the MAR?
• Are the mg, mcg, mL
the same?
• Is your math correct?
• Double check!!
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The RIGHT Patient
• Have you checked
using two patient
identifiers?
– Patient
states…..verifies DOB
– Patient armband –
compare to information
on MAR
– What if there is no arm
band?
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The RIGHT Time
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AM or PM
Q4
Tid
Bid
Qid
Qd
HS
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The RIGHT Route
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PO
IV
SC (SQ)
TRANSDERMAL
RECTAL
IM
Does it make sense?
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RIGHT Documentation
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MOD – Medication on Demand
• The Radio Frequency
Identification (RFID) based wrist
band
• The first of its kind to be
implemented successfully
• Assists nurses by automating the
process of administering patient
medication
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ROUTES OF
ADMINISTRATION
• PO – Per Os/ by
mouth
• SL – Sublingual
• Buccal
• Inhaled
• Intranasal
• AD/AS/AU - Ears
• OD/OS/OU –
Intraocular [eyes]
• Topical - Skin
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IO - intraosseous
PR – per rectum
Vaginal
IM - Intramuscular
IV – Intravenous
SC - Subcutaneous
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SYSTEMS OF MEDICATION
MEASUREMENT
• METRIC SYSTEM
– ml, mg, mcg, gm
• HOUSEHOLD MEASUREMENTS
– Tsp, gtts
• APOTHECARY
– Drams, grains
• Know conversions/ carry table
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ORAL ADMINISTRATION OF
MEDICATION
• SOLID FORMS
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CAPLET
CAPSULE
TABLET
GELCAP
ENTERIC COATED
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ORAL ADMINISTRATION OF
MEDICATION
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LIQUID FORMS
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ELIXIR
• CONTAINS ALCOHOL EITHER AS INGREDIANT OR
FLAVORING
EXTRACT
• SEPARATE FROM BASE INGREDIENT
• (VANILLA EXTRACT)
AQUEOUS SOLUTION/ SUSPENSION
• PARTICLES MIXED WITH BUT NOT DISSOLVED IN WATER
SYRUP
• MIXED WITH SUGAR AND WATER
TINCTURE
• MEDICINE IN ALCOHOL BASE
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ORAL ADMINISTRATION OF
MEDICATION
• OTHER ORAL FORMS
– TROCHE / LOZENGE
• NOT MEANT TO BE SWALLOWED
– AEROSOL
• TOPICAL
– SUSTAINED RELEASE
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ORAL ADMINISTRATION
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BUCCAL ADMINISTRATION
OF MEDICATION
• BETWEEN THE CHEEK AND GUMS
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TABLET
SEMI-SOLID
PASTE
THICK LIQUID
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SUBLINGUAL
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TOPICAL APPLICATION
• SPRAYS
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ORAL
TOPICAL
NASAL
INHALED
• Creams/
Ointments
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• VAGINAL/RECTAL
– SUPPOSITORIES
• EAR DROPS
– POSITION EAR
• EYE DROPS
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PARENTERAL
ADMINISTRATION
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INTRAMUSCULAR IM
SUBCUTANEOUS SC
INTRADERMAL [like TB test]
INTRAVENOUS IV
INTRAOSEOUS IO
EPIDURAL
INTRATHECAL (SUBARACHNOID SPACE)
INTRAPERITONEAL
INTRAPLEURAL
INTRARTERIAL
INTRARTICULAR [in a joint]
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INTRAMUSCULAR
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PAIN MEDICATION
ANTIBIOTICS
VACCINATIONS
SUPPLEMENTS
– IRON
– B12
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IM Injection Sites
Ventrogluteal
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Vastus Lateralis
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Deltoid
Injection
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INJECTION ANGLES
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Subcutaneous injection
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Sub Q administration sites
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Intradermal Injection
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Syringes – NOT interchangeable
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Sizes of Needles
Length 3/8” to 3”
Gauge 30 – 19
20-22G, 1-1.5” for IM
25-30G, 3/8-1/2” for
SQ
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Nursing Roles
• Legal and Ethical implications
• Know your meds
– Pharmacokinetics:
• Because food, other drugs, disease, age affect
absorption, distribution, metabolism, excretion
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Actions
Interactions
Routes
Measurement and Calculation, conversions
Documentation
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Responsibilities
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Prescribe – APN
Correct drug and dose [range]
Effects and implications
Why med is ordered for pt
Monitor effects – intended and other
Reactions
Education
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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
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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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Test Your Knowledge
• The nurse is transcribing the physician’s orders
for the newly admitted client’s medications.
For which of the following orders would the
nurse need clarification prior to administering
the medication?
A) Digoxin 0.125 mg po daily
B) Lasix 40 mg. po bid
C) Tylenol 650 mg. po PRN
D) Lipitor 20 mg. po at bedtime
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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
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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
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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 is present Blood serum concentration is
in concentration great
reached and maintained
enough to produce response
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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
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Interferes with absorption of
tetracycline antibiotics
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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
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Insulin Preparation
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Rapid, short, intermediate, and long acting
Know onset, peak and duration (see page 743)
ONLY regular insulin can be given IV
Sliding scale based on blood glucose
Gently roll cloudy
DO NOT SHAKE
Prepare last and administer first if mixed because
regular can become “contaminated” and action can be
affected
– CLEAR to CLOUDY
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Drug Calculations
Dose Ordered X amount = amount to
dose on hand
on hand administer
1. Look at order + available concentration
2. Ballpark estimate
3. Calculate – paper + calculator
4. Check math, compare to estimate
Convert to same units [mcg, mg]
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Examples
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1.
2.
Order: Digoxin 12.5mg PO daily
On hand: 25 mg tablets
Change to same units if needed [mg= mg]
Put in formula: 12.5 X 1 tab = ?
25
amount to give
3. Estimate: 12.5 is about ½ of 25
4. Solve: ½ X 1 = ½ tab
5. Check estimate – ½ = ½
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Wait!
• You’re not done yet:
• Nursing implications for Digoxin:
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Assess and record apical HR and B/P
Hold for systolic B/P < 90, HR <60
Know WHY
Know action of Digoxin
Document HR, B/P, dose given or held, time
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Example 2
• Order: APAP gtts 5mg/kg q 4° PO
fever/pain
• Available: 80mg/0.8ml [= 100mg/1ml]
• Wt is 3 kg
• 5 mg X 3 kg = 15 mg dose
• Estimate: 100 mg in 1 ml, dose is 15
mg; will be very small dose - < 1 ml
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Solve
15ml [ordered] X 1ml = ? amount
100mg [on hand]
to give
15mg/100mg X 1 ml = 0.15ml
Check – close to estimate? [if I mess up my
math and get 1.5 ml, estimate will catch me]
Administer and document
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PRACTICE
• You CANNOT Practice medication
calculations too much
• KEY skill for success in school &
practice
• PRACTICE, PRACTICE, PRACTICE
• Know conversions, abbreviations
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Abbreviations to Avoid
• Trailing Zero e.g. 1.0ml [read as 10ml]
• Lack of leading zero e.g. .1mg [read as 1mg]
• X3D ?? Three doses or three days?
• Drug abbreviations MgSO4 – [mag sulfate]
– Read as Morphine Sulfate [MSO4]
• Similar Drug names – clarify
[Norvasc/Norflex, Fosamax/ Flomax]
• Handwritten Orders/ MARS – Always Clarify
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Medication References
• Book form –
– In med room, on Pyxis
• Electronic –
– Available for PDA, Itouch, Iphone
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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
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Nursing Diagnoses
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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
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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
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Goals
• Generally: safe administration, knowledge
• Pt will demonstrate safe and effective
technique for preparing sliding scale insulin
based on blood sugar within 24 hours
• Pt will correctly demonstrate subcutaneous
insulin administration before discharge
• Pt will verbalize understanding of side
effects of prescribed medications after this
teaching session
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Goals, con’t
• You must monitor a client’s response to
meds on an on-going basis
– Goal is not evaluated just once in practice
– E.g. Pain is 3/10 in 30 minutes – good; keep
checking
• The goals of safe and effective med
administration involve the client’s response
to therapy and ability to assume
responsibility for safe self-care
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Interventions
• Administer medications per orders
• Assess need for PRN meds
• Assess/monitor medication effects [side
effects, desired effect, toxic effects]
• Teach/ educate pt/family –
– How to measure accurately
– Administration [safety]
– Side effects, when to call DR
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Evaluation
• Was goal met? Partially met? Not met?
• Pt correctly calculates insulin [sliding scale]
based on BG
• Demonstrates safe preparation and
administration
• Verbalizes side effects
• Asks for pain medication when pain 3/10
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Revising Plan
• 1. If short term goal was met, reinforce,
continue, or reset goal [increase
independence, etc]
• 2. if partially met, reinforce teaching,
promote safety, assess what is needed
• 3. Goal not met? Assess why not, change
method, add [pain med plus ice and rest]
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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 – many drugs = interactions
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Test Your Knowledge
• The nurse is teaching a client how to
prepare 10 units of regular and 5 units of
NPH insulin for injection. In what order
should the nurse instruct the client to do the
following?
A) Inject air into the regular insulin
B) Inject air into the NPH insulin
C) Withdraw the regular insulin
D) WithdrawNRS105
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NPH insulin
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Intravenous Administration
• Nurses administer meds IV in the following
ways:
– As mixtures within large volumes of IV fluids (Banana
bag)
– By injection of a bolus or small volume of med through
an existing IV line or intermittent venous access
(heparin lock/saline lock/buff cap)
– By “piggyback” infusion of a solution containing the
prescribed medication and a small volume of IV fluid
through an existing IV line
• You are responsible for reading more about this in your text
as there may be questions on the HESI 
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Peripheral IV
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IV Solution and Pump
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Patient Controlled Analgesia
(PCA)
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Central Venous Catheters
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Test Your Knowledge
• If a client who is receiving intravenous
(IV) fluids develops tenderness, warmth,
erythema, and pain at the site, the nurse
suspects which of the following?
A) Sepsis
B) Phlebitis
C) Infiltration
D) Fluid overload
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IV Care
• PICC lines, central lines should be
marked – treated differently
• Disinfect skin [surgically] prior to
starting IV; otherwise medical asepsis
• Scrub the hub 15 seconds each time
• PICC – surgical asepsis for dressing
changes
• Central lines are conduits [like Foleys]
– high infection risk
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