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 patients
  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 Ws 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 clients 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
  nurses 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 patients 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 JCAHOs 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 patients currently prescribed medications
  with those just ordered during the current visit.

18
Legal Implications for Medication Administration

• Nurses 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

• Patients 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
• gt for greater than
• lt for less than
• Abbreviations for drug names
• Apothecary units
• _at_ for at
• C.c. for cubic centimeters
• Ug for microgram

See Study Guide 7 for more information
28
Sources for Locating Drug Information

• Physicians 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 - Persons 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 its 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 drugs 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

51
Patient Teaching

• To grant legal consent to treatment, patients
  must be informed about drug regimen
• Assess patients knowledge of medication
• Provide information about purpose of drug, action
  and side effects
• Teach how to self-administer
• drugs and incorporate into
• daily routines

52
Route of Administration

• Depends upon
• Drug characteristic
• Desired responses
• Each route has advantages/disadvantages

53
Oral Route

• Simple and convenient
• Relatively inexpensive
• Can be used by most people
• Disadvantages
• Slower drug action
• Irritation of GI tract

54
Oral Administration

• Assess patient
• Can the patient swallow?
• Crush tablets if appropriate
• Dont crush enteric coated or time-released
  capsules
• Crushed tablets may be mixed with food

55
Oral Administration (continued)

• 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

56
Oral Administration (continued)

• Liquid medications
• 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

57
Sublingual and Buccal Administration

• 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

58
Topical Administration

• Primarily provides local effect
• Clean off old medication
• Apply using appropriate device
• Special Considerations
• Nitroglycerine (NTG)
• Transdermal Meds

59
Rectal Administration

• Assess the patient
• 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.

60
Vaginal Administration

• Cleanse perineum
• Insert applicator 2 inches
• Cleanse patient after administration

61
Inhalant Administration

• 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

62
Nasal Administration

• Have patient blow nose
• Have patient keep head back
• Push up tip of nose
• Place tip of administration device slightly
  inside nose
• May cause aspiration

63
Ophthalmic (Eye) Administration

• 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

64
Otic (Ear) Administration

• Position patient with affected side up
• Straighten ear canal up and back
• Adult up and back
• children under 3 pull down and back
• Warm the solution slightly
• Mineral oil is sometimes used in advance to
  soften wax prior to flushing.
• Instill drops into the ear canal

65
Parenteral Route

• 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

66
Parenteral Administration

• Equipment
• 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 lt 1 ml, use TB or I ml syringe
• Use an insulin syringe for insulin

67
Equipment for Injections

• Choice of needle gauge depends upon
• 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

68
Medications in Ampules Vials

• 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

69
Subcutaneous Administration (SQ)

• 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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70
Subcutaneous (continued)

• 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

71
Intradermal Administration (ID)

• 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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72
Intramuscular Administration (IM)

• 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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73
Intramuscular Injection Sites

• Dorsogluteal
• Ventrogluteal
• Deltoid
• Vastus Lateralis

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74
Intramuscular Administration

• Use 21-22g needle
• Insert at 90 degree angle
• Max volume 5 ml usually doses of 1-3 ml

75
Intramuscular Administration

• Z-Track
• For solutions irritating
• to the tissues

• Pull skin away from site to displace tissue
• Inject medication
• Dont massage after injection

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76
Intravenous Administration (IV)

• 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

77
Intravenous Administration (continued)

• Advantages
• Client comfort
• Easy access for nurses
• Disadvantages
• Time and skill required for venapuncture
• Difficulty in maintaining an IV line
• Greater potential for adverse reactions
• Possible complications of IV therapy

78
Intravenous Administration (continued)

• Assess IV insertion site
• Pain
• Redness
• Bleeding
• Swelling
• Dressing dry and intact

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79
Nursing Care with IV Medications

• 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

80
Nursing Care (continued)

• When discontinuing IV catheter on a client on
  anticoagulants, prolonged pressure may be
  required
• Document as per policy

81
Intravenous Piggyback (IVPB)

• 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

82
Intermittent IV Therapy

• 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

83
Intravenous Push (IVP) Administration

• The medication is pushed into the port by the
  nurse
• Before pushing, the nurse must know
• If the medication is compatible with the existing
  IV fluid
• The rate that the push should be given
• usually in minutes

84
Intravenous Administration - Equipment

• 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 physicians order
• Check for kinks or obstructions frequently

85
Central Lines

• Terminate in the jugular vein, subclavian vein,
  brachial vein or even into the right atrium
• Strict sterile technique must be followed when
  accessing these
• Sterile gloves, masks
• Peripheral intravenous infusion catheter (PICC)

86
Calculating Dosages

• 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.
87
Calculating Dosages (continued)

• 250 500 (cross multiply and divide)
• 1 x
• 500/250 2
• The answer is 2 tablets

88
Calculating Dosages (continued)

• 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.
89
Calculating Dosages (continued)

• 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

90
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.
91
Calculating Dosages (continued)

• 5,000 units x (cross multiply and
  divide)
• 10,000 units 1
• 5000/10,000 ½ or 0.5
• The answer is 0.5 ml

92
Calculating Dosages (continued)

• Practice the following (dose based on weight)
• Medication order Lovenox 1mg/kg BID
• Dose/quantity on hand 80mg/ml
• Patients weight 154 pounds
• ?? of ml required

And the answer is.
93
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

94
Photo AcknowledgementAll unmarked photos and
clip art contained in this module were obtained
from the 2003 Microsoft Office Clip Art Gallery.