Adams ch03 lecture

PHARMACOLOGY FOR NURSESPHARMACOLOGY FOR NURSESA Pathophysiological ApproachA Pathophysiological Approach

FOURTH EDITIONFOURTH EDITION

CHAPTER

Principles of Drug Administration

Pharmacology for Nursing: A Pathophysiology Approach, Fourth EditionMichael Patrick Adams | Leland N. Holland | Carol Urban

The Nursing Process in Drug The Nursing Process in Drug AdministrationAdministration

• Nurses are expected to understand the pharmacotherapeutic principles for all medications given to each patient.

Nurse ResponsibilitiesNurse Responsibilities

• Know classifications, actions, and side effects of drug

• Know patient details and why drug was prescribed

• Know how drug is acquired and pharmacy procedures

• Know how to prepare and administer drug safely

Nurse ResponsibilitiesNurse Responsibilities

• Before drug is administered, the nurse must know all variables of the patient's condition.

• Be prepared to recognize and react to adverse effects

Five Most Common Medication Five Most Common Medication ErrorsErrors

• Incomplete patient information• Unavailable drug information• Miscommunication of drug orders• Lack of appropriate drug labeling• Environmental distractions

Allergic ReactionsAllergic Reactions

• Allergic reaction—an acquired hyperresponse of body defenses to a foreign substance– If discovered, nurse responsible for

labeling charts, informing all personnel, and placing alert bracelet on patient

AnaphylaxisAnaphylaxis

• A severe allergic reaction involving the massive, systemic release of histamine and other chemical mediators of inflammation that can lead to life-threatening shock

• Requires immediate treatment

Five Rights of Drug AdministrationFive Rights of Drug Administration

• Five rights used as the basis of safe delivery of medications. They are:– Right patient– Right medication– Right dose– Right route of administration– Right time of delivery

Three Checks of Drug Three Checks of Drug AdministrationAdministration

• Checking the drug with the MAR or the medication information system when pulling it from storage

• Checking the drug when preparing it, pouring it, taking it out of the unit-dose container, or connecting the IV tubing to the bag

• Checking the drug before administering it to the patient

Mistakes and LiabilityMistakes and Liability

• Despite five rights and three checks, mistakes still occur.

• Nurses are held accountable for correct administration of drugs, but responsibility also rests on other positions like physician and pharmacist.

Drug ComplianceDrug Compliance

• Compliance is taking a medication in the manner prescribed by the health care provider.– Patient has an active role in ensuring

compliance.

Drug ComplianceDrug Compliance

• Factors that can cause a patient to deviate from compliance:– Cost of drug– Forgetting doses– Annoying side effects– Self-adjustment of doses– Fear of dependency

• Nurse must be vigilant in questioning patients about their medications.

Special Drug-Administration Special Drug-Administration AbbreviationsAbbreviations

• STAT – medication is to be given immediately, and only once.

• ASAP – drug should be available for administration within 30 minutes of the written order.

• PRN – drug is administered as required by the patient's condition.

Table 3.1 Drug Administration Abbreviations

continued on next slide

Table 3.1 (continued) Drug Administration Abbreviations

Drug-Administration AbbreviationsDrug-Administration Abbreviations

• Do not use these abbreviations: qd, qhs, qod

Drug-Administration Written Drug-Administration Written OrdersOrders

• Single order—drug is to be given only once at a specific time.

• Orders not written as STAT, ASAP, NOW, or PRN are called routine orders.

• Standing order—written in advance of a situation that is to be carried out under specific circumstances.

Drug-Administration ProceduresDrug-Administration Procedures

• Drug orders must be reviewed by the attending physician within specific time frames, at least every 7 days.

• Drugs may need administration during or between meals, depending on interaction with food.

• Central nervous system drugs and antihypertensives are often best administered at bedtime.

Drug-Administration ProceduresDrug-Administration Procedures

• Nurses must educate patients carefully about timing of taking medications.

• Nurses must document carefully the details of medications given to patient—after they have been given.– Refusal or omission of medication must

be documented.

Three Systems of Measurement Three Systems of Measurement Used in PharmacologyUsed in Pharmacology

• Metric—most common• Apothecary—oldest• Household

Nurse Must Be Able to Convert Nurse Must Be Able to Convert Among All Three SystemsAmong All Three Systems

• Metric, Apothecary, and Household Approximate Measurement Equivalents

• Joint Commission (JCAHO), the accrediting organization for health care agencies, has placed apothecary measurements on its “do not use” list.

• Nurses should encourage use of accurate medical dosing devices at home.

Table 3.2 Metric, Apothecary, and Household Approximate Measurement Equivalents

Routes of AdministrationRoutes of Administration

• Three broad routes are enteral, topical, and parenteral.– Subsets within each

Common Protocols and Techniques for Common Protocols and Techniques for All Routes of AdministrationAll Routes of Administration

• Review medication order• Wash hands and apply gloves, if

indicated• Identify patient, check for allergies• Inform patient

Common Protocols and Techniques for Common Protocols and Techniques for All Routes of AdministrationAll Routes of Administration

• Position patient, remove drug from prepackaging if necessary; do not leave drugs at bedside unless so instructed

• Document

Enteral RouteEnteral Route

• Enteral route includes drugs administered:– By mouth

tablets, capsules, sublingual and buccal– Via nasogastric tube or gastrostomy

Enteral RouteEnteral Route

• Tablets and capsules most common form of drugs– Can be crushed or opened only if

manufacturer instructed; enteric-coated tablets must remain intact

• Sustained-release tablets or capsules are designed to dissolve very slowly.– Created to increase compliance by

reducing frequency of dosage

Table 3.3 Enteral Drug Administration

Table 3.3 (continued) Enteral Drug Administration

Sublingual and Buccal Drug Sublingual and Buccal Drug AdministrationAdministration

• Tablet is kept in mouth.• Sublingual

– Medication is placed under the tongue and allowed to dissolve slowly. Rich blood supply causes rapid onset.

– Used only after oral medications have been swallowed, if multiple drugs are ordered

– No food or drink until completely dissolved

Figure 3.1a Sublingual drug administration

Sublingual and Buccal Drug Sublingual and Buccal Drug AdministrationAdministration

• Buccal– Tablet or capsule placed in oral cavity

between the gum and the cheek– Preferred for sustained delivery– Generally does not cause irritation– Like sublingual drugs, buccal drugs are

formulated to bypass first-pass metabolism.

Figure 3.1b Buccal drug administration

Nasogastric and Gastronomy Drug Nasogastric and Gastronomy Drug AdministrationAdministration

• Nasogastric (NG) tube is a soft, flexible tube inserted by way of the nasopharynx with the tip lying in the stomach.– Generally for short-term treatment

Nasogastric and Gastronomy Drug Nasogastric and Gastronomy Drug AdministrationAdministration

• Gastrostomy (G) tube is surgically placed directly into the patient's stomach.– Longer-term treatment

• Both methods generally use liquid drugs.

Enteral Drug Administration Enteral Drug Administration AdvantagesAdvantages

• Convenient• Least costly of three routes• Overdose can be countered by retrieval

of undigested medicines through vomiting.

Enteral Drug Administration Enteral Drug Administration AdvantagesAdvantages

• Safest route because skin barrier not compromised

• Uses vast absorptive surfaces of the oral mucosa, stomach, or small intestine

Enteral Drug Administration Enteral Drug Administration Disadvantages Disadvantages

• Difficulty swallowing by some patients• May be inactivated if tablets or

capsules crushed or opened• Can be inactivated by enzymes• Depends on patient gastrointestinal

motility and mobility• First-pass metabolism: inactivation of

drug by processing in the liver

Topical Drugs Are Applied to Skin Topical Drugs Are Applied to Skin or Mucous Membranesor Mucous Membranes

• Applications:– Dermatologic preparations: applied to

skin—most common– Instillations and irrigations: applied into

body cavities and orifices– Inhalations: applied to the respiratory

tract by inhalers, nebulizers, or positive-pressure breathing

Purposes of Topical DrugsPurposes of Topical Drugs

• Many intended for local effect—for example antibiotics to treat a skin infection

• Fewer side effects because generally absorbed very slowly

Purposes of Topical DrugsPurposes of Topical Drugs

• Some given for slow absorption into general circulation, designed for their systemic effects– Systemic vs. local effect is important

distinction for a nurse.

Transdermal Delivery SystemTransdermal Delivery System

• Transdermal patches provide effective means of delivering some medications.

• Rate of delivery and dose may vary with drug.

• Avoids first-pass effect of liver and enzymes

• Full documentation by nurses applies.

Figure 3.2a Transdermal patch administration: protective coating removed from patch

Figure 3.2b Transdermal patch administration: patch immediately applied to clean, dry, hairless skin and labeled with date, time, and initials

Opthalmic AdministrationOpthalmic Administration

• Used to treat local conditions of the eye and surrounding structures

• Common indications of problems:– Excessive dryness, infections, glaucoma,

and dilation of the pupil during eye examinations

• Special procedures, sometimes even immobilization, may be needed for children.

Figure 3.3 Instilling an eye ointment into the lower conjunctival sac

Otic AdministrationOtic Administration

• Used to treat local conditions of the ear, including infections and soft blockages of the auditory canal

• Eardrops, irrigations• Usually used for cleaning purposes

Figure 3.4 Instilling eardropsSource: Andy Crawford/Dorling Kindersley.

Table 3.4 Topical Drug Administration

Table 3.4 (continued) Topical Drug Administration

Nasal AdministrationNasal Administration

• For both local and systemic administration

• Ease of use, avoids first-pass effect and digestive enzymes

• Mucosal irritation common; potential for damage

Nasal AdministrationNasal Administration

• Often used for local astringent effect—shrink swollen mucous membranes or loosen secretions and facilitate drainage

Figure 3.5 Nasal drug administration

Vaginal AdministrationVaginal Administration

• For treating local infections and to relieve vaginal pain and itching

• Suppositories, creams, jellies, or foams• Nurse must explain the purpose of

treatment and provide for privacy and patient dignity.

Figure 3.6a Vaginal drug administration: instilling a vaginal suppository

Figure 3.6b Vaginal drug administration: using an applicator to instill a vaginal cream

Rectal AdministrationRectal Administration

• Local or systemic administration• Usually suppository form, but

sometimes administered as enema• First-pass effect and digestive enzymes

avoided

Parenteral Drugs Are Parenteral Drugs Are Administered via NeedleAdministered via Needle

• Types: intradermal, subcutaneous, intramuscular, intravenous

• Require aseptic technique• Nurse must have knowledge of

anatomical locations.• Nurse must know correct equipment to

use.• Nurse must know procedure for

disposing of hazardous equipment.

Parenteral LocationsParenteral Locations

• Intradermal: dermal layer of skin• Subcutaneous: deepest layers of the

skin• Intramuscular: specific muscles• Intravenous: directly into bloodstream• Advanced parenteral delivery may be

directly into body cavities or organs.

Intradermal and Subcutaneous Intradermal and Subcutaneous AdministrationsAdministrations

• Avoid the hepatic first-pass effect and digestive enzymes; offer method for those who cannot take medicine orally

• Only small volumes can be administered; injections can cause pain and swelling.

• Intradermal (ID) injection administered into the dermis layer of the skin– More easily absorbed than in

subcutaneous– Small amount of drug

Figure 3.7a Intradermal drug administration: cross section of skin showing depth of needle insertion

Figure 3.7b Intradermal drug administration: the administration site is prepped

Figure 3.7c Intradermal drug administration: the needle is inserted, bevel up at 10–15°

Figure 3.7d Intradermal drug administration: the needle is removed and the puncture site is covered with an adhesive bandage

• Subcutaneous injection is delivered to the deepest layers of the skin.

• Used for easy access and rapid absorption

• Important to rotate injection sites• Aspiration not usually necessary, but

depends on drug

Figure 3.8a Subcutaneous drug administration: cross section of skin showing depth of needle insertion

Figure 3.8b Subcutaneous drug administration: the administration site is prepped

Figure 3.8c Subcutaneous drug administration: the needle is inserted at a 45° angle

Figure 3.8d Subcutaneous drug administration: the needle is removed and the puncture site is covered with an adhesive bandage

Intramuscular AdministrationIntramuscular Administration

• Delivers medication into specific muscles

• More rapid onset of action than with oral, ID, or subcutaneous administration

• Can accept larger volume of medication than subcutaneous

• Injection site very important; must avoid bone, blood vessels, and nerves

Figure 3.9a Intramuscular drug administration: cross section of skin showing depth of needle insertion

Figure 3.9b Intramuscular drug administration: the administration site is prepped

Figure 3.9c Intramuscular drug administration: the needle is inserted at a 90° angle

Figure 3.9d Intramuscular drug administration: the needle is removed and the puncture site is covered with an adhesive bandage

Four Common Intramuscular Four Common Intramuscular Injection SitesInjection Sites

• Ventrogluteal• Deltoid• Dorsogluteal• Vastus lateralis

Table 3.5 Parenteral Drug Administration

Table 3.5 (continued) Parenteral Drug Administration

Intravenous Administration (IV)Intravenous Administration (IV)

• Medications and fluids are administered directly into the bloodstream and are immediately available for use by the body.

• Fastest drug onset action, but also most dangerous method– Contaminations– Swift adverse reactions

Figure 3.10 Injecting a medication by IV push

Three Types of Intravenous Three Types of Intravenous AdministrationAdministration

• Large-volume infusion: for fluid maintenance, replacement, or supplementation

• Intermittent infusion: small amount of IV solution arranged tandem with primary large-volume infusion; used to instill adjunct medications

Three Types of Intravenous Three Types of Intravenous AdministrationAdministration

• IV bolus (push) administration: concentrated dose delivered directly to circulation via syringe to administer single-dose medications

Figure 3.11 Intravenous drug administrationSource: Paul Velgos/iStockphoto

Parenteral Advantages and Parenteral Advantages and Disadvantages Disadvantages

• Advantages:– Bypasses first-pass effect and enzymes– Available to patients unable to take

medication orally• Disadvantages:

– Only small doses can be used– Pain and swelling at injection site

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