Chapter 35: Medication Administration

1. Chapter 35: Medication Administration Bonnie M. Wivell, MS, RN, CNS

2. Introduction 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

3. 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 Control medication sales and distribution Medical testing Naming and labeling Regulate controlled substances

4. 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

5. 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 Health Care Institutions and Medical Laws establish policies to meet federal, state, and local regulations. Regulate size of institution, types of services, types of medical personnel employed Purpose is to protect the public from unskilled, undereducated, and unlicensed personnel. Health Care Institutions and Medical Laws establish policies to meet federal, state, and local regulations. Regulate size of institution, types of services, types of medical personnel employed Purpose is to protect the public from unskilled, undereducated, and unlicensed personnel.

6. 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

7. Patient Safety Patient Safety To err is Human

8. Leape, L. L. and Berwick, D. M. (2005). Five years after �To Err Is Human�: What have we learned? Retrieved 8/1/10 from http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2005/May/Five-Years-After--To-Err-Is-Human---What-Have-We-Learned.aspx Leape, L. L. and Berwick, D. M. (2005). Five years after �To Err Is Human�: What have we learned? Retrieved 8/1/10 from http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2005/May/Five-Years-After--To-Err-Is-Human---What-Have-We-Learned.aspx

9. 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

10. 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

11. 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 Absorption - depends on route, [skin � slow, mucus membranes � quick, oral � slower, IV � most rapid] Safe medication administration requires knowledge of factors that alter or impair absorption of prescribed medications. Because some medications interact with food, it is often appropriate to administer them before or after meals, with meals, or on an empty stomach. Absorption - depends on route, [skin � slow, mucus membranes � quick, oral � slower, IV � most rapid] Safe medication administration requires knowledge of factors that alter or impair absorption of prescribed medications. Because some medications interact with food, it is often appropriate to administer them before or after meals, with meals, or on an empty stomach.

12. 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 2. Rate and extent of distribution depends on physical and chemical properties of medication and the physiology of the client. 3. Medication has entered into the bloodstream, -carried throughout the tissues and organs of the body. -speed of the distribution depends on the vascularity of the various tissues and organs. To be distributed to an organ, medication has to pass through the organ�s tissues and biological membranes. Some membranes serve as barriers to the passage of medications. For example, blood-brain area allows fat-soluble medications to pass into the brain and CSF. Both fat-soluble and non�fat-soluble agents often cross the placenta and produce fetal abnormalities such as respiratory depression. Narcotic use can create withdrawal symptoms.2. Rate and extent of distribution depends on physical and chemical properties of medication and the physiology of the client. 3. Medication has entered into the bloodstream, -carried throughout the tissues and organs of the body. -speed of the distribution depends on the vascularity of the various tissues and organs. To be distributed to an organ, medication has to pass through the organ�s tissues and biological membranes. Some membranes serve as barriers to the passage of medications. For example, blood-brain area allows fat-soluble medications to pass into the brain and CSF. Both fat-soluble and non�fat-soluble agents often cross the placenta and produce fetal abnormalities such as respiratory depression. Narcotic use can create withdrawal symptoms.

13. 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 What will happen to medications if the organs used for breakdown are not functioning correctly? TOXICITYWhat will happen to medications if the organs used for breakdown are not functioning correctly? TOXICITY

14. Excretion Medications are excreted through: Kidney Liver Bowel Lungs Exocrine glands Ask students: 1. What is the main organ for excretion? KIDNEYS 2. Which type of medications are excreted through the lungs? Anesthetic gases, alcohol Why should certain medications not be taken during pregnancy? Some may pass through the placental barrier or mammary glands. Example � opioids, tranquilizers, anti-emetics TeratogenicAsk students: 1. What is the main organ for excretion? KIDNEYS 2. Which type of medications are excreted through the lungs? Anesthetic gases, alcohol Why should certain medications not be taken during pregnancy? Some may pass through the placental barrier or mammary glands. Example � opioids, tranquilizers, anti-emetics Teratogenic

15. Types of Medication Action 1. Therapeutic effect � desired effect, primary effect intended, reason drug prescribed Side Effects � secondary effect produced at a usual therapeutic dose; may be either harmless or cause injury; If serious enough to negate benefit then d/c drug Adverse effect � sometimes immediate, but often take weeks or months to develop. Early recognition key; d/c immediately and report to MedWatch Toxic effects � results from overdose, buildup of the drug in the blood because of impaired metabolism or excretion Idiosyncratic reaction � one that is unexpected and may be individual to a client May have a completely different effect from the normal one Benedryl makes child hyper instead of sleepy Ativan makes adult hyper instead of drowsy Allergic reaction � immunologic reaction to a drug, or client may produce antibodies to the drug (antigen), its chemical preservatives or a metabolite Mild or severe � anaphylactic � life threatening, characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and SOB .1. Therapeutic effect � desired effect, primary effect intended, reason drug prescribed Side Effects � secondary effect produced at a usual therapeutic dose; may be either harmless or cause injury; If serious enough to negate benefit then d/c drug Adverse effect � sometimes immediate, but often take weeks or months to develop. Early recognition key; d/c immediately and report to MedWatch Toxic effects � results from overdose, buildup of the drug in the blood because of impaired metabolism or excretion Idiosyncratic reaction � one that is unexpected and may be individual to a client May have a completely different effect from the normal one Benedryl makes child hyper instead of sleepy Ativan makes adult hyper instead of drowsy Allergic reaction � immunologic reaction to a drug, or client may produce antibodies to the drug (antigen), its chemical preservatives or a metabolite Mild or severe � anaphylactic � life threatening, characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and SOB .

16. 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

17. Medication Dose Responses Drug half life � time required to reduce the concentration of the drug to � it was at initial administration; to maintain therapeutic, need to receive drug at regular fixed intervals Onset � time after administration when the body initially responds to the drug Peak � highest plasma level achieved by the drug when elimination rate of drug equals absorption rate, so occurs just before the body absorbs the last of the medication Trough � Minimum blood serum concentration before next scheduled dose Plateau � maintained concentration of a drug in the plasma during a series of scheduled dosesDrug half life � time required to reduce the concentration of the drug to � it was at initial administration; to maintain therapeutic, need to receive drug at regular fixed intervals Onset � time after administration when the body initially responds to the drug Peak � highest plasma level achieved by the drug when elimination rate of drug equals absorption rate, so occurs just before the body absorbs the last of the medication Trough � Minimum blood serum concentration before next scheduled dose Plateau � maintained concentration of a drug in the plasma during a series of scheduled doses

18. Routes of Administration Oral � most common, least expensive, most convenient Disadvantage is taste, irritation of gastric mucosa, irregular absorption, slow absorption, some cases harm to teeth (liquid iron � straw) Vomiting, NG tube, NPO Sublingual � under tongue, dissolves, absorbed into blood vessels on underside of tongue Med should not be swallowed Nitroglycerine Buccal � pertaining to the cheek � held in mouth against mucous membranes of cheek until dissolves Drug may act locally on mucous membranes or systemically when swallowed in saliva (example: Fentanyl lollypop) Parenteral � involves injecting a med into body tissues By needle � SQ, IM, Intradermal, IV Epidural � into edipural space Intrathecal or intraspinal � into subarachnoid space or one of the ventricles of the brain (ommaya reservoir) Intraosseous � directly into bone marrow, most commonly used in infants and toddlers with poor IV access Intraperitoneal � peritoneal cavity Intrapleural � pleural space via chest tube Intraarterial � IV Topical � applied to a certain surface area of body affecting only that area to which it is applied Dermatologic � skin, transdermal patch has systemic effects Instillations and irrigations � body cavities, orifices (eyes, ears, nose, throat gargle or swab, vagina, bladder, rectum) Inhalations � administered to respiratory tract by nebulizer, vapor, carried into lungs; work rapidly because of the rich vascular alveolar capillary network; have local or systemic effectsOral � most common, least expensive, most convenient Disadvantage is taste, irritation of gastric mucosa, irregular absorption, slow absorption, some cases harm to teeth (liquid iron � straw) Vomiting, NG tube, NPO Sublingual � under tongue, dissolves, absorbed into blood vessels on underside of tongue Med should not be swallowed Nitroglycerine Buccal � pertaining to the cheek � held in mouth against mucous membranes of cheek until dissolves Drug may act locally on mucous membranes or systemically when swallowed in saliva (example: Fentanyl lollypop) Parenteral � involves injecting a med into body tissues By needle � SQ, IM, Intradermal, IV Epidural � into edipural space Intrathecal or intraspinal � into subarachnoid space or one of the ventricles of the brain (ommaya reservoir) Intraosseous � directly into bone marrow, most commonly used in infants and toddlers with poor IV access Intraperitoneal � peritoneal cavity Intrapleural � pleural space via chest tube Intraarterial � IV Topical � applied to a certain surface area of body affecting only that area to which it is applied Dermatologic � skin, transdermal patch has systemic effects Instillations and irrigations � body cavities, orifices (eyes, ears, nose, throat gargle or swab, vagina, bladder, rectum) Inhalations � administered to respiratory tract by nebulizer, vapor, carried into lungs; work rapidly because of the rich vascular alveolar capillary network; have local or systemic effects

24. Effects of Nutrition on Drugs

25. 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 Metric, apothecaries and household Metric � organized in units of 10, Multiplied by moving decimal to right Divided by moving decimal to left Units � meter (length), liter (volume), gram (weight) Meds are ordered in weight (grams, mg, mcg) and administered by volume (mL) Apothecaries � older than metric Basic unit is grain � (grain of wheat), minim (volume) � volume of water the weight of a grain of wheat Expressed as Roman numerals - gr ii, < 1 expressed as fraction gr 1/6 Household � least accurate Drops, teaspoons, tablespoons, cups, glasses Solutions are used for irrigations, injections, and infusions. A solution is defined - solid substance dissolved in a known volume of fluid or as a given volume of liquid dissolved in a known volume of another fluid. Metric, apothecaries and household Metric � organized in units of 10, Multiplied by moving decimal to right Divided by moving decimal to left Units � meter (length), liter (volume), gram (weight) Meds are ordered in weight (grams, mg, mcg) and administered by volume (mL) Apothecaries � older than metric Basic unit is grain � (grain of wheat), minim (volume) � volume of water the weight of a grain of wheat Expressed as Roman numerals - gr ii, < 1 expressed as fraction gr 1/6 Household � least accurate Drops, teaspoons, tablespoons, cups, glasses Solutions are used for irrigations, injections, and infusions. A solution is defined - solid substance dissolved in a known volume of fluid or as a given volume of liquid dissolved in a known volume of another fluid.

26. 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)

27. 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 Health care institutions have specific regulations regarding the ordering of medications. The use of abbreviations when ordering medications is often the cause of medication errors. Only approved abbreviations can be used. You will need to refer to your specific health care facility for the list of approved abbreviations. Additionally, the Joint Commission has a list of its approved abbreviations.Health care institutions have specific regulations regarding the ordering of medications. The use of abbreviations when ordering medications is often the cause of medication errors. Only approved abbreviations can be used. You will need to refer to your specific health care facility for the list of approved abbreviations. Additionally, the Joint Commission has a list of its approved abbreviations.

28. Types of Orders in Acute Care Agencies 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 Standing orders � A standing order is an order from a physician, usually for multiple items, that is entered and does not require any further communication from a nurse to the physician. For example, a physician may order immunizations as a standing order. When a patient is admitted to the hospital, those standing orders apply and a patient may receive the order without the nurse calling for a specific order on the patient.  - patients coming into nursing home usually are administered pneumonia and flu shots and have PPD - Demerol 100mg IM q4h X 5 days � usually automatically cancelled after a certain number of days Standing orders � A standing order is an order from a physician, usually for multiple items, that is entered and does not require any further communication from a nurse to the physician. For example, a physician may order immunizations as a standing order. When a patient is admitted to the hospital, those standing orders apply and a patient may receive the order without the nurse calling for a specific order on the patient. - patients coming into nursing home usually are administered pneumonia and flu shots and have PPD - Demerol 100mg IM q4h X 5 days � usually automatically cancelled after a certain number of days

29. 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 Most agencies have doctor sign order within 24 � 48 hours, some don�t accept verbal orders, doc must write or type order Question if order ambiguous, unusual, contraindicated by client�s condition Nursing students never allowed to accept verbal or telephone orderMost agencies have doctor sign order within 24 � 48 hours, some don�t accept verbal orders, doc must write or type order Question if order ambiguous, unusual, contraindicated by client�s condition Nursing students never allowed to accept verbal or telephone order

30. Components 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

32. Medication Administration Pharmacist�s role Distribution system Medication errors (near miss) Medication Reconciliation Verify Clarify Reconcile Transmit Nurse�s role 1. Pharmacist � prepares, distributes, mixes (IV) prescribed medications. -work with other health care providers to provide information side effects, toxicity, interactions, and incompatibilities. 2. Medications are distributed in many formats. -unit dose and -automated medication dispensing systems pyxis 4. Medication errors can cause the client harm, - include inaccurate prescribing or administration or -giving it via the wrong route or -frequency. Documentation is required within 24 hours when an error is made. A 2007 National Patient Safety Goal is for medication reconciliation (compares the meds the client took in the previous setting with the client�s current med orders. Medication errors may be lessened when the SIX rights of medication administration are followed1. Pharmacist � prepares, distributes, mixes (IV) prescribed medications. -work with other health care providers to provide information side effects, toxicity, interactions, and incompatibilities. 2. Medications are distributed in many formats. -unit dose and -automated medication dispensing systems pyxis 4. Medication errors can cause the client harm, - include inaccurate prescribing or administration or -giving it via the wrong route or -frequency. Documentation is required within 24 hours when an error is made. A 2007 National Patient Safety Goal is for medication reconciliation (compares the meds the client took in the previous setting with the client�s current med orders. Medication errors may be lessened when the SIX rights of medication administration are followed

33. The Six Rights of Medication Administration Right medication Right dose Right patient Right route Right time Right documentation Right to refuse

34. 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.

36. Potential Medication Error

37. 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

38. The Nursing Process and Med Administration 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

39. Nursing 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

40. 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

41. Implementation 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 Implementation will include promoting or maintaining the client�s health and factors to improve their health. Each acute care setting has specific regulations regarding medication administration. Nursing students are never allowed to accept verbal or telephone orders. Each health care facility also has policies regarding transcribing and communicating orders, calculating dosages, and documenting medication administration. Implementation will include promoting or maintaining the client�s health and factors to improve their health. Each acute care setting has specific regulations regarding medication administration. Nursing students are never allowed to accept verbal or telephone orders. Each health care facility also has policies regarding transcribing and communicating orders, calculating dosages, and documenting medication administration.

42. 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 Polypharmacy�taking two or more medications to treat the same illness. When a client takes two or more meds from the same class, when the client uses two or more meds with the same or similar actions to treat several disorders simultaneously, or when a client mixes nutritional supplements or herbal preps with meds.Polypharmacy�taking two or more medications to treat the same illness. When a client takes two or more meds from the same class, when the client uses two or more meds with the same or similar actions to treat several disorders simultaneously, or when a client mixes nutritional supplements or herbal preps with meds.

43. 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

44. Will cover actual administration and other issues surrounding administration during tomorrow�s class QUESTIONS?