Transcript Pharmacological Therapy Part 1

Module 7
Pharmacology I:
Medication Administration
1
Safe Practices in Medication
Administration
2
“7 Rights” of Safe Medication
Administration
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Right Drug
Right Dose
Right Time
Right Route
Right Patient
Right Reason
Right Documentation
3
“7 Rights” (continued)
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Right Drug
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Check all orders, labels and confirm that the
drug is appropriate for this client/condition
Right Dose
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Is the dose is appropriate for the drug, age,
size and patient condition
4
“7 Rights” (continued)
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Right Time
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Follow agency policy
Right Route
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Follow medication order and knowledge of
appropriate routes for specific drugs
5
“7 Rights” (continued)
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Right Patient
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Right Reason
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ALWAYS identify the patient 2 ways (the patient’s
room number should not be one of the options)
Requires knowledge of medication; knowledge of
patient; question appropriateness of order if
applicable
Right Documentation
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Follow agency policy and procedure for immediate
documentation = time, route, response
6
Right Documentation
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Remember the 5 W’s when documenting
medication administration on chart:
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When (time)
Why (include assessment, symptoms,
complaints, lab)
What (medication, dose, route)
Where (site)
Was (med tolerated?/helpful to the patient?)
(See Study Guide #2 for additional charting tips and
legal aspects of medication documentation)
7
Medication Documentation
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First, make sure you have the right chart!
Never chart a drug before it is administered
Documenting includes name of drug, dosage,
route, and time
Record location when giving parenteral
medications
Follow agency policy if a medication
was not given
Document client’s response to the
medication
8
Preventing Medication Errors
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Minimize verbal and telephone orders
Refrain from attempting to decipher
illegibly written orders
Always adhere to the 7 rights
Read the label 3 times, checking against
the medication administration record
Listen to the patient - any concerns are the
nurse’s concerns!
9
Preventing Medication Errors (continued)
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Double check with literature if in doubt
about an order
Minimize interruptions while processing
and preparing medications
Do not agree to give medications in an area
where you are not experienced
10
Nursing Process and Medication
Administration
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Assessment
 Medication history, allergies, ability to take
med in the form provided?
Diagnosis
 Is this the right drug, dose, patient, etc?
Planning
 How will the drug be given?
Implementation
 Correct route; need for standard precautions?
Evaluation
 Was the medication effective?
11
Patient Assessments in Medication
Administration
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Assess patient variables that might
influence drug therapy.
Assess drug history prior to the start of a
new drug
Assess patient’s response to the medication
Assess physical parameters prior to
administration
 Apical pulse, BP
12
Nursing Responsibilities in Medication
Administration
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Be knowledgeable about medications being administered and
being taken by the patient
Know what to do in the event of an adverse reaction
Verify and clarify orders that seem inappropriate
Be knowledgeable and informed concerning agency policies,
especially concerning JCAHO’s National Patient Safety Goals
Follow standards of nursing practice
Observe standard precautions and use medical-surgical
asepsis if indicated
Confirm “7 rights” of safe medication administration
Document medication delivery and patient response
accurately and appropriately
Report adverse events or incidents per agency policy
13
Medical-Surgical Asepsis and Medication
Administration
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Medical Asepsis
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Handwashing
Standard precautions
Surgical Asepsis
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Use of sterile supplies
14
National Patient Safety Goals related to
Medication Administration
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Use at least 2 patient identifiers just prior
to medication administration. (i.e. ask the
patient to relate to you their name and
date of birth)
Verify verbal or telephone orders by
verbally reading back the order to the
Licensed Independent Practitioner (LIP)
out loud.
15
National Patient Safety Goals related to
Medication Administration (continued)
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Take action to prevent errors involving
sound-alike or look-alike drugs (see agency
policy for specific precautions and actions
to implement)
Label all medications containers both on
and off the sterile field. (This applies to
syringes of drawn-up medications to be
given later, medication cups of oral
medications to be given later, etc.)
16
National Patient Safety Goals related to
Medication Administration (continued)
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Follow agency policy concerning a
comparison of the patient’s currently
prescribed medications with those just
ordered during the current visit.
17
Legal Implications for Medication
Administration
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Nurse’s roles and responsibilities for
administration of medications are defined
and described by standards of care and the
Nurse Practice Act
Additionally, there are agency specific
policies and procedures
18
U.S. Laws Affecting Medication
Administration
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Food, Drug & Cosmetic Act – (1906)
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Required accurate labeling and testing for
harmful effects
1962 added requirement of proof of safety and
effectiveness
Harrison Narcotic Act (1914)
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Established legal term “narcotic”
Regulated importation, manufacture, sale and
use of habit-forming drugs
19
U.S. Laws Affecting Medication
Administration (continued)
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Durkham-Humphrey Amendment (1952)
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Clearly differentiates drugs that can be sold
only with a prescription, those that can be sold
without a prescription, and those that cannot be
refilled without a new prescription.
20
U.S. Laws Affecting Medication
Administration (continued)
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Controlled Substance Act- (1970)
Also known as: Comprehensive Drug Abuse
Prevention and Control Act
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In response to growing misuse/abuse of drugs
Categorizes controlled substances
Limits how often a prescription can be filled
Established government-funded programs to
prevent and treat drug dependence
21
U.S. Laws Affecting Medication
Administration (continued)
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Comprehensive Drug Abuse Prevention
and Control Act (continued)
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Promotes drug education
Strengthens enforcement authority
Establishes treatment and rehabilitation
facilities
22
Schedules of Controlled
Substances
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See schedules Study Guide 5
Give an example of one drug from each
category
23
Rules Governing Administration of
Controlled Substances
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Keep in “burglar” proof containers
Double-locked carts or cabinets
Accurately complete controlled Substance
Inventory form
2 nurses must witness and document
when wasting a controlled substance
24
Medication Orders…
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Should be written clearly, legibly and in
easy-to-understand language
Should be clarified if unclear – check with
direct supervisor first.
Should not include blanket, summary
statements such as “resume all pre-op
orders”
25
Essential Parts of a Medication Order
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Patient’s full name
Date and time order written
Name of medication to be administered
Dosage (strength and amount to be given)
Frequency of administration
Route
Number of doses or days medication is to
be given
Signature of the ordering physician
26
“Do-Not-Use” Abbreviations
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U for unit
IU for international unit
Q.D., qd, QOD, q.o.d.
A trailing zero (i.e. 2.0 mg. Instead use 2 mg)
MS, MSO4, MgSO4
> for greater than
< for less than
See Study Guide 7
Abbreviations for drug names
for more
Apothecary units
information
@ for at
C.c. for cubic centimeters
Ug for microgram
27
Sources for Locating Drug
Information
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Physician’s Desk Reference
National Formulary or Hospital Formulary
Pharmacists
Drug reference books
Pharmacology textbooks
Computer-based Indexes
28
Drug Misuse
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Drug misuse - Improper use of any
medication which leads to acute/chronic
toxicity
Drug abuse - Inappropriate intake of a
substance
29
Drug Dependence
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Drug dependence - Person’s reliance on or
need to take a substance
Physiological dependence – biochemical
changes in body tissue, especially the
nervous system, which lead to a
requirement by the tissues to function
normally
Psychological dependence – emotional
reliance to maintain a sense of well-being
30
Pharmacokinetics
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“What the body does to the drug”
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Absorption
Distribution
Metabolism/Biotransformation
Excretion
31
Pharmacokinetics
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(continued)
Drug Effects
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Onset- Time it takes for a therapeutic response
Peak - Time it takes for maximum therapeutic
response
Duration of action - Length of time that drug
concentration is sufficient for a therapeutic
response
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4 Factors Affecting Absorption
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Route of administration and conditions at
absorption site
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Oral medications have slowest rate of
absorption
IV drugs the fastest
Drug dosage and form
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Enteric coatings delay absorption
Liquid form absorbed faster than pills
Some parenteral/topicals have additives that
delay/prolong absorption
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Factors Affecting Absorption (continued)
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Fat (lipid) solubility
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More lipid soluble the more rapid it’s absorption
Gastrointestinal factors
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Gastric emptying time
Motility - diarrhea, constipation
Presence of food
Integrity of GI tract
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4 Factors Affecting Distribution
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Blood flow
Plasma protein binding
Amount of the drug
Physiological barriers to absorption
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Blood-brain-barrier
Placental barrier
35
4 Factors Affecting
Metabolism/Biotransformation
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Condition of the liver
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Age
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Infants and elderly usually have decreased
metabolism of drug
Nutritional status
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Liver filters most medications
malnutrition
Hormones
36
2 Factors Affecting Excretion
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Renal excretion
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Drugs are filtered in or out by kidneys
Renal pathology will decrease excretion
Decreased excretion increases circulating
blood levels of the drug
Liver or lung pathology
37
Drug Half-Life
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The time it takes for ½ of the original amt of the
drug to be removed from the body
Useful for determining amount of drug in blood
level in relation to amount removed by
elimination
Used to determine the frequency of drug
administration
38
Pharmacodynamics
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“How the drug affects the body”
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Biological, chemical, and physiologic actions of
a drug within the body
Drugs can promote, block, or turn on/off a
response
They cannot create a new response
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Loading Dose
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A loading dose is one that is larger than
the standard dose:
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It is given at the beginning of drug therapy to
quickly raise the blood level of the drug into
therapeutic range.
It is used when the desired therapeutic
response is required more quickly than can be
achieved with the standard dose.
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Maintenance Dose
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A maintenance dose is one that continues
to keep the drug in the desired therapeutic
range:
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It is used after a loading dose.
For many drugs, patients receive the
maintenance dose both at the start of therapy
and throughout therapy.
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Therapeutic Index
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Relates to drug’s margin of safety, the ratio
of effective dose to a lethal dose
42
Tolerance
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Means that a larger dose is needed to
bring about the same response
43
Adverse Effect
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Any non-therapeutic response to the drug
therapy-consequences may be minor or
significant
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Drug Interactions
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Action of one drug on a second drug or
other element creating one or more of the
following:
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Increased or decreased therapeutic effect of
either or both drugs
A new effect
An increase in the incidence of an adverse effect
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Causes of Drug Interactions
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GI absorption
Enzyme induction
Renal excretion
Pharmacodynamic effects
Patient care variables
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Allergic Reactions
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Allergic reactions are altered physiologic
reactions to a drug that occur because a
prior exposure to the drug stimulated the
immune system to develop antibodies.
Anaphylaxis is the most serious allergic
reaction.
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Accumulation
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Occurs when the dosage exceeds the
amount the body can eliminate through
metabolism and excretion
Is called toxicity if tissue/organ damage
occurs
Factors contributing to accumulation:
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Age
Underlying disease
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Toxicity: Evaluating Drug Levels
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When receiving certain medications, blood
samples are drawn to maintain blood levels
within a therapeutic margin
Peak: draw a peak level 30 min after IV
administration and 1 hour after IM
administration
Trough: draw a trough level just before the
next dose (sometimes before the 3rd dose)
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Nursing Responsibilities for Toxicity
Assess for signs of:
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Ototoxicity: balance and hearing
Nephrotoxicity: I & O, proteinuria
GI toxicity: diarrhea
Neurotoxicity: drowsiness, seizures
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Patient Teaching
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To grant legal consent to treatment, patients
must be informed about drug regimen
Assess patient’s knowledge of medication
Provide information about purpose of drug, action
and side effects
Teach how to self-administer
drugs and incorporate into
daily routines
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Route of Administration
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Depends upon:
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Drug characteristic
Desired responses
Each route has advantages/disadvantages
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Oral Route
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Simple and convenient
Relatively inexpensive
Can be used by most people
Disadvantages:
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Slower drug action
Irritation of GI tract
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Oral Administration
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Assess patient
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Can the patient swallow?
Crush tablets if appropriate
Don’t crush enteric coated or time-released
capsules
Crushed tablets may be mixed with food
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Oral Administration (continued)
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Preparation
 Solid medications can be put in the same
cup except when special assessment like
blood pressure or apical pulse is required
 Unit dose can be kept in original package
 Always place bottle or container caps
upside down on counters or tables
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Oral Administration (continued)
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Liquid medications
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Shake to mix
Pour away from the label
Use the appropriate measuring device
like a medicine cup or syringe
Avoid alcohol based meds with alcohol addicted
persons
Use a straw for liquid iron preparations
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Sublingual and Buccal Administration
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Prevents destruction in the GI tract
Allows rapid absorption into the bloodstream
Sublingual tablets placed under the tongue;
buccal tablets placed between upper or lower
molars in cheek area (alternate sides)
Instruct patient to allow medication to dissolve &
not drink until completely dissolved
57
Topical Administration
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Primarily provides local effect
Clean off old medication
Apply using appropriate device
Special Considerations
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Nitroglycerine (NTG)
Transdermal Meds
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Rectal Administration
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Assess the patient
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GI function and Anal Competence
Keep suppository in refrigerator until ready to
administer
Place patient in left lateral position
Lubricate the suppository
Insert past the internal sphincter
For enemas, have them retain for 20 to 30
minutes.
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Vaginal Administration
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Cleanse perineum
Insert applicator 2 inches
Cleanse patient after administration
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Inhalant Administration
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Check vital signs
Have patient exhale deeply
before activating device
Have patient close lips around the
mouthpiece without touching it
Use spacer device when needed
61
Nasal Administration
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Have patient blow nose
Have patient keep head back
Push up tip of nose
Place tip of administration device slightly
inside nose
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May cause aspiration
62
Ophthalmic (Eye) Administration
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If possible, use warm solution
Administer with patient supine or sitting
up with head back
Have patient look up
Place drop in conjunctival sac
Have patient blink to distribute the
medication
63
Otic (Ear) Administration
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Position patient with affected side up
Straighten ear canal up and back
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Warm the solution slightly
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Adult: up and back
children under 3: pull down and back
Mineral oil is sometimes used in advance to
soften wax prior to flushing.
Instill drops into the ear canal
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Parenteral Route
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Refers to any route other than
gastrointestinal
Commonly: SC, IM, IV Injections
Must be prepared, packaged and
administered to maintain sterility
Multi-dose vials
Single dose vials
65
Parenteral Administration
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Equipment
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Use only sterile needles and syringes
Needles and syringes are available in various
gauges and volumes. The larger the syringe the
lower the injection pressure
For volumes < 1 ml, use TB or I ml syringe
Use an insulin syringe for insulin
66
Equipment for Injections
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Choice of needle gauge depends upon:
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Route of administration
Viscosity of the solution
Size of the client
Usually: 25-gauge 5/8 inch needle SC
and Intradermal
20-or 22-gauge, 1½ inch needle for IM
67
Medications in Ampules & Vials
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Ampules are sealed glass containers
The top is broken; medication is removed
by needle & syringe (use a filter needle)
Unused portions must be discarded
Vials with powdered form, follow directions
to dilute with sterile water or normal
saline
68
Subcutaneous Administration (SQ)
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Injection of drugs under the skin
Used for small volume (1 ml)
Absorption is slower
Drug action is usually longer
Drugs that are irritating to tissues
cannot be given SC
Common sites:
upper arms, abdomen, thighs
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69
Subcutaneous (continued)
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Use 25-27 gauge needle
Gather tissue in opposition and pull up
slightly
Insert needle at 45 or 90 degree angle
using a pushing action
Do not aspirate
If anti-blood clotting agent, do not massage
site
70
Intradermal Administration (ID)
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Use 26-27 gauge needle
Apply traction to skin near site
Place needle with bevel upward
Inject small wheel at site and
withdrawal needle
Do not massage
Maximum volume = 0.1ml
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71
Intramuscular Administration (IM)
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Involves injection of drugs into muscle
Absorption is more rapid due to blood
supply
Incorrect injection techniques may damage
blood vessels and nerves
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72
Intramuscular Injection Sites
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Dorsogluteal
Ventrogluteal
Deltoid
Vastus Lateralis
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73
Intramuscular Administration
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Use 21-22g needle
Insert at 90 degree angle
Max volume 5 ml; usually doses of 1-3 ml
74
Intramuscular Administration
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Z-Track
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For solutions irritating
to the tissues
Pull skin away
from site to
displace tissue
Inject medication
Don’t massage
after injection
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75
Intravenous Administration (IV)
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Involves injection of drugs directly into
bloodstream
Drugs act rapidly
Administered through established IV line
or direct injection into the vein (in
emergencies)
Used for intermittent or continuous
infusions
76
Intravenous Administration (continued)
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Advantages:
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Client comfort
Easy access for nurses
Disadvantages:
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Time and skill required for venapuncture
Difficulty in maintaining an IV line
Greater potential for adverse reactions
Possible complications of IV therapy
77
Intravenous Administration (continued)
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Assess IV insertion site:
 Pain
 Redness
 Bleeding
 Swelling
 Dressing dry and intact
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78
Nursing Care with IV Medications
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Use standard precautions
Wipe “port” with alcohol before accessing
Strict sterile technique when preparing
medication
New guidelines require IV securing device,
transparent dressing or sterile tape to
secure catheter to the patient
79
Nursing Care (continued)
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When discontinuing IV catheter on a client
on anticoagulants, prolonged pressure may
be required
Document as per policy
80
Intravenous Piggyback (IVPB)
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IVPB is a small volume of medication that
is attached or “piggybacked” into the port
of an existing IV line
Alcohol the port before attaching the
piggyback tubing
81
Intermittent IV Therapy
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Patient may have a saline lock (heparin
lock) without a primary IV running
through it
Used just for intermittent medications
Flush before and after medication with
normal saline
82
Intravenous Push (IVP) Administration
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The medication is pushed into the port by
the nurse
Before pushing, the nurse must know:
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If the medication is compatible with the
existing IV fluid
The rate that the push should be given
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usually in minutes
83
Intravenous Administration - Equipment
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Pumps
 Deliver in ml/hour; most pumps deliver
to the tenths place (ex: 85.5 ml/hour)
 Check IV site before connecting to pump
 Set rate according to physician’s order
 Check for kinks or obstructions
frequently
84
Central Lines
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Terminate in the jugular vein, subclavian
vein, brachial vein or even into the right
atrium
Strict sterile technique must be followed
when accessing these
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Sterile gloves, masks
Peripheral intravenous infusion catheter
(PICC)
85
Calculating Dosages
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Practice the following:
Dose on hand = 250mg
Quantity on hand: 1 tablet = 250mg
Desired dose (dose ordered) = 500mg
?? = # of tablets required
And the answer is….
86
Calculating Dosages (continued)
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250
1
= 500 (cross multiply and divide)
x
500/250 = 2
The answer is 2 tablets
87
Calculating Dosages (continued)
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Practice the following (requires
conversion):
Dose on hand = 250mg
Quantity on hand: 1 capsule = 250mg
Desired dose (dose ordered) = 0.5gm
?? = # of tablets required
And the answer is….
88
Calculating Dosages (continued)
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Convert 0.5gm to mg. 1 gm = 1000mg so
0.5 gm = 500mg
250 = 500 (cross multiply and divide)
1
x
500/250 = 2
The answer is 2 tablets
89
Calculating Dosages (continued)

Practice the following (units):
Dose on hand = 10,000 units
Quantity on hand: 10,000 units per 1 ml
Desired dose (dose ordered) = 5000 units
?? = # of ml required
And the answer is….
90
Calculating Dosages (continued)

5,000 units =
divide)
10,000 units =
x (cross multiply and
1

5000/10,000 = ½ or 0.5

The answer is 0.5 ml
91
Calculating Dosages (continued)

Practice the following (dose based on
weight):
Medication order: Lovenox 1mg/kg BID
Dose/quantity on hand = 80mg/ml
Patient’s weight = 154 pounds
?? = # of ml required
And the answer is….
92
Calculating Dosages (continued)

Convert pounds to kilograms (2.2 lbs = 1
kg)
154/2.2 = 70kg

1mg x 70kg = 70mg




Cross multiply and divide:
80mg = 70mg  70/80 = 0.8
1ml =
x
The answer is 0.8 ml
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Photo Acknowledgement:
All unmarked photos and clip art contained in
this module
were obtained from the
2003 Microsoft Office Clip Art Gallery.
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