Module 7

1. Module 7 Pharmacology I: Medication Administration

2. Safe Practices in Medication Administration

3. “7 Rights” of Safe Medication Administration • Right Drug • Right Dose • Right Time • Right Route • Right Patient • Right Reason • Right Documentation

4. “7 Rights” (continued) • Right Drug • Check all orders, labels and confirm that the drug is appropriate for this client/condition • Right Dose • Is the dose is appropriate for the drug, age, size and patient condition

5. “7 Rights” (continued) • Right Time • Follow agency policy • Right Route • Follow medication order and knowledge of appropriate routes for specific drugs

6. “7 Rights” (continued) • Right Patient • ALWAYS identify the patient 2 ways (the patient’s room number should not be one of the options) • Right Reason • Requires knowledge of medication; knowledge of patient; question appropriateness of order if applicable • Right Documentation • Follow agency policy and procedure for immediate documentation = time, route, response

7. Right Documentation • Remember the 5 W’s when documenting medication administration on chart: • 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)

8. Medication Documentation • 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

9. Preventing Medication Errors • 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!

10. Preventing Medication Errors (continued) • 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

11. Nursing Process and Medication Administration • 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?

12. Patient Assessments in Medication Administration • 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

13. Nursing Responsibilities in Medication Administration • 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

14. Medical-Surgical Asepsis and Medication Administration • Medical Asepsis • Handwashing • Standard precautions • Surgical Asepsis • Use of sterile supplies

15. National Patient Safety Goals related to Medication Administration • 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.

16. National Patient Safety Goals related to Medication Administration (continued) • 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.)

17. National Patient Safety Goals related to Medication Administration (continued) • Follow agency policy concerning a comparison of the patient’s currently prescribed medications with those just ordered during the current visit.

18. Legal Implications for Medication Administration • 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

19. U.S. Laws Affecting Medication Administration • Food, Drug & Cosmetic Act – (1906) • Required accurate labeling and testing for harmful effects • 1962 added requirement of proof of safety and effectiveness • Harrison Narcotic Act (1914) • Established legal term “narcotic” • Regulated importation, manufacture, sale and use of habit-forming drugs

20. U.S. Laws Affecting Medication Administration (continued) • Durkham-Humphrey Amendment (1952) • 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.

21. U.S. Laws Affecting Medication Administration (continued) • Controlled Substance Act- (1970) • Also known as: Comprehensive Drug Abuse Prevention and Control Act • 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

22. U.S. Laws Affecting Medication Administration (continued) • Comprehensive Drug Abuse Prevention and Control Act (continued) • Promotes drug education • Strengthens enforcement authority • Establishes treatment and rehabilitation facilities

23. Schedules of Controlled Substances • See schedules Study Guide 5 • Give an example of one drug from each category

24. Rules Governing Administration of Controlled Substances • 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

25. Medication Orders… • 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”

26. Essential Parts of a Medication Order • 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

27. “Do-Not-Use” Abbreviations • 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 • Abbreviations for drug names • Apothecary units • @ for at • C.c. for cubic centimeters • Ug for microgram See Study Guide 7 for more information

28. Sources for Locating Drug Information • Physician’s Desk Reference • National Formulary or Hospital Formulary • Pharmacists • Drug reference books • Pharmacology textbooks • Computer-based Indexes

29. Drug Misuse • Drug misuse - Improper use of any medication which leads to acute/chronic toxicity • Drug abuse - Inappropriate intake of a substance

30. Drug Dependence • 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

31. Pharmacokinetics • “What the body does to the drug” • Absorption • Distribution • Metabolism/Biotransformation • Excretion

32. Pharmacokinetics (continued) • Drug Effects • 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

33. 4 Factors Affecting Absorption • Route of administration and conditions at absorption site • Oral medications have slowest rate of absorption • IV drugs the fastest • Drug dosage and form • Enteric coatings delay absorption • Liquid form absorbed faster than pills • Some parenteral/topicals have additives that delay/prolong absorption

34. Factors Affecting Absorption (continued) • Fat (lipid) solubility • More lipid soluble the more rapid it’s absorption • Gastrointestinal factors • Gastric emptying time • Motility - diarrhea, constipation • Presence of food • Integrity of GI tract

35. 4 Factors Affecting Distribution • Blood flow • Plasma protein binding • Amount of the drug • Physiological barriers to absorption • Blood-brain-barrier • Placental barrier

36. 4 Factors Affecting Metabolism/Biotransformation • Condition of the liver • Liver filters most medications • Age • Infants and elderly usually have decreased metabolism of drug • Nutritional status • malnutrition • Hormones

37. 2 Factors Affecting Excretion • Renal excretion • 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

38. Drug Half-Life • 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

39. Pharmacodynamics • “How the drug affects the body” • 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

40. Loading Dose • A loading dose is one that is larger than the standard dose: • 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.

41. Maintenance Dose • A maintenance dose is one that continues to keep the drug in the desired therapeutic range: • It is used after a loading dose. • For many drugs, patients receive the maintenance dose both at the start of therapy and throughout therapy.

42. Therapeutic Index • Relates to drug’s margin of safety, the ratio of effective dose to a lethal dose

43. Tolerance • Means that a larger dose is needed to bring about the same response

44. Adverse Effect • Any non-therapeutic response to the drug therapy-consequences may be minor or significant

45. Drug Interactions • Action of one drug on a second drug or other element creating one or more of the following: • Increased or decreased therapeutic effect of either or both drugs • A new effect • An increase in the incidence of an adverse effect

46. Causes of Drug Interactions • GI absorption • Enzyme induction • Renal excretion • Pharmacodynamic effects • Patient care variables

47. Allergic Reactions • 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.

48. Accumulation • 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: • Age • Underlying disease

49. Toxicity: Evaluating Drug Levels • 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)

50. Nursing Responsibilities for Toxicity Assess for signs of: • Ototoxicity: balance and hearing • Nephrotoxicity: I & O, proteinuria • GI toxicity: diarrhea • Neurotoxicity: drowsiness, seizures