Chapter 35: Medication Administration
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Transcript of Chapter 35: Medication Administration
Chapter 35: Medication Chapter 35: Medication AdministrationAdministration
Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS
IntroductionIntroduction• Medication is a substance used in the
– Diagnosis– Treatment– Cure– Relief– Prevention of health alterations
• The nurse is responsible for the following in regard to medications:– Preparation– Administration– Teaching– Evaluating response
Medication Legislation and Medication Legislation and StandardsStandards
• 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
– Control medication sales and distribution– Medical testing– Naming and labeling– Regulate controlled substances
Medication Legislation and Medication Legislation and Standards Cont’d.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 Medication Legislation and Standards Cont’d.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 SubstancesControlled 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 SafetyPatient 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 ConceptsPharmacological 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.Pharmacological Concepts Cont’d.• Classification
– 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
PharmacokineticsPharmacokinetics• 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
DistributionDistribution• 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
MetabolismMetabolism
• 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
ExcretionExcretion
• Medications are excreted through: –Kidney–Liver–Bowel–Lungs–Exocrine glands
Types of Medication ActionTypes of Medication Action
Therapeutic effect:Therapeutic effect:Expected or predictableExpected or predictable
Side effect:Side effect:Predictable and often Predictable and often unavoidableunavoidable
Adverse effect:Adverse effect:Unintended, undesirable, Unintended, undesirable, and often unpredictable and often unpredictable severe responsesevere response
Toxic effect:Toxic effect:Medication Medication accumulates in the accumulates in the blood streamblood stream
Idiosyncratic reaction:Idiosyncratic reaction:Over- or under-reaction to Over- or under-reaction to a medicationa medication
Allergic reaction:Allergic reaction:Unpredictable response Unpredictable response to a medicationto a medication
Medication InteractionsMedication 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 ResponsesMedication Dose ResponsesSerum half-life:Serum half-life:Time for serum medication Time for serum medication concentration to be halvedconcentration to be halved
Onset:Onset:Time it takes for a Time it takes for a medication to produce a medication to produce a responseresponse
Peak:Peak:Time at which a medication Time at which a medication reaches its highest effective reaches its highest effective concentrationconcentration
Trough:Trough:Time at which drug is at its Time at which drug is at its lowest amount in the serumlowest amount in the serum
Duration:Duration:Time medication takes to Time medication takes to produce a responseproduce a response
Plateau:Plateau:Blood serum concentration is Blood serum concentration is reached and maintainedreached and maintained
Routes of AdministrationRoutes of Administration
OralOralSwallow, Sublingual, BuccalSwallow, Sublingual, Buccal
ParenteralParenteralID, Sub-Q, IM, IVID, Sub-Q, IM, IV
OtherOtherEpidural, Intrathecal, Epidural, Intrathecal, Intraosseous, Intraosseous, Intraperitoneal, Intrapleural, Intraperitoneal, Intrapleural, IntraarterialIntraarterial
TopicalTopicalSkinSkin
Transdermal patchTransdermal patch
Instillation or irrigationInstillation or irrigation
InhalationInhalationNasal passages, oral Nasal passages, oral passage, ET or trachpassage, ET or trach
IntraocularIntraocularInsertion of disk containing Insertion of disk containing med; dropsmed; drops
Effects of Nutrition on DrugsEffects of Nutrition on DrugsGrapefruit Can cause toxicity when taken
with cisapride, carbamazepine, diazepam, verapamil, amiodarone, lovastatin
Vitamin K Decrease effectiveness of warfarin
Tyramine (found in cheese, beer, dried sausage, sauerkraut)
In combination with MAOI meds (Nardil, Parnate, Marplan) creates increase in epinephrine HA, ↑ P, ↑ BP death
Milk Interferes with absorption of tetracycline antibiotics
Systems of Medication Systems of Medication MeasurementMeasurement
• 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 BaseNursing 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’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 Types of Orders in Acute Care AgenciesAgencies
• 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 OrderCommunication 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 OrdersComponents of Medication Orders
• 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 AdministrationMedication Administration• 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 The Six Rights of Medication AdministrationAdministration
• Right medication
• Right dose
• Right patient
• Right route
• Right time
• Right documentation
• Right to refuse
Where Do Drugs Come From in the Where Do Drugs Come From in the Hospital?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 ErrorPotential Medication Error
Critical ThinkingCritical 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 The Nursing Process and Med AdministrationAdministration
• Assessment– 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 DiagnosisNursing Diagnosis• 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
PlanningPlanning
• 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
ImplementationImplementation• Health promotion
– Client and family teaching• Acute care
– 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 ConsiderationsSpecial 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
EvaluationEvaluation• 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?