Chapter 30 Medication Administration Copyright 2004 by Delmar

Drug Standards and Legislation § Standards have been developed to ensure drug uniformity so that the effects of the medication are predictable. § The Pure Food and Drug Act (1906) designated official references. • United States Pharmacopeia (USP) • National Formulary (NF) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 2

Drug Standards and Legislation § Official Canadian references • British Pharmacopeia • Canadian Formulary

Federal Standards and Legislation § Harrison Narcotic Act (1914) classified habit-forming drugs as narcotics and regulated the dispensing of prescription drugs. § Comprehensive Drug Abuse Prevention and Control Act (Controlled Substance Act, 1970) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 4

Federal Standards and Legislation § Comprehensive Drug Abuse Prevention and Control Act (Controlled Substance Act, 1970) • Defines a drug-dependent person. • Established five categories of scheduled drugs (controlled substances). • Provides for strict regulation of controlled substances. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 5

Federal Standards and Legislation § Drug Enforcement Administration (DEA) • Employs pharmacists to inspect all types of records, including prescriptions. • Detects the illicit distribution of controlled substances. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 6

State and Local Legislation § State practice acts define required education and skill levels of all statelicensed nurses. § States have the power to enforce additional regulations beyond federal mandates. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 7

Health Care Institution Regulations § Required to meet minimum standards set by federal, state, and local agencies. § Institutional policies are typically more restrictive. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 8

Medication Names § Drug, medication, and medicine are oftenused interchangeably. § The term drug is basically defined as anysubstance that can modify one or more of the body’s functions. § A medication (or medicine) is a drug that is used for a therapeutic effect. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 9

Classification of Medications § Medications are commonly classified by the body system that they interact with, or in accordance with therapeutic usage. § Medications with multiple therapeutic uses are usually classified in accordance with their most common usage. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 11

Forms of Medication Preparations § Drugs are available in many forms for administration by a specific route. § The route refers to how the drug is absorbed. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 12

Forms of Medication Preparations § Oral Solids • • Tablets Capsules Caplets Powder and

Forms of Medication Preparations § Oral Solids • • Troches, lozenges, and pastilles Enteric-coated tablets Time-release capsules Sustained-release compound substances Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 14

Forms of Medication Preparations § Topical • • • Powder Liniments Ointments Pastes Transdermal

Forms of Medication Preparations § Inhalants • Drugs administered by the nasal or oral respiratory route for a local or systemic effect Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 16

Forms of Medication Preparations § Solutions • • Enemas Douches Suspensions Emulsions Copyright 2004

Forms of Medication Preparations § Solutions • • • Syrups Gargles Mouthwashes Nasal solutions Optic (eye) and otic (ear) Elixirs Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 18

Pharmacokinetics § The study of the absorption, distribution, metabolism, and excretion of drugs to determine the relationship between the dose of a drug and the drug’s concentration in biological fluids Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 19

Pharmacokinetics § Absorption • Passage of a drug from the site of administration into the bloodstream. - Physicochemical effects Dosage form Route of administration Interactions with other substances Client characteristics Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 20

Pharmacokinetics § Distribution • Movement of medications from the blood into various body fluids and tissues. - Blood flow - Cell membrane permeability - Protein-binding capacity of the medication Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 21

Pharmacokinetics § Metabolism (biotransformation) • Inactivates the medication and changes it into a form that can be excreted more easily. - Presence of enzymes in the liver - Diseases and other conditions - Genetic factors Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 22

Pharmacokinetics § Excretion • The process in which drugs are eliminated from the body. • Excretion occurs primarily through the liver/biliary system and the kidneys. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 23

Medication Action § Local action at the cellular or organ level § Systemic action, effecting changes throughout the body § Both local and systemic actions § Drug action is based on the half-life of a drug. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 24

Medication Management of Drug Levels § Maintaining a constant drug level within therapeutic range. § Therapeutic range is the range of drug concentration in the blood, which gives the desired effect without causing serious side effects or toxicity. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 25

Factors Which Alter Medication Action § Medication Interaction § Food and Drug Interactions § Client Factors Influencing Drug Action • • Client’s diet Renal and liver function Genetic factors Amount of body fat Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 26

Nontherapeutic Drug Actions § § § Side Effects Adverse Reactions Toxic Effects Drug Allergy Idiosyncratic Reaction Drug Tolerance Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 27

Routes of Medication Administration § Oral Route § Parenteral • • • Intradermal (ID) Subcutaneous (SC or SQ) Intramuscular (IM) Intravenous (IV) Other parenteral routes Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 28

Nontherapeutic Drug Actions § Topical Route • Local effect on the skin or mucous membrane • Systemic effect by absorption into the blood stream § Inhalants § Intraocular Route Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 29

Professional Roles in Medication Administration § Health Care Practitioner § Nurse § Pharmacist Copyright

Professional Roles in Medication Administration § Types of Medication Orders • • Stat Orders Single-Dose Orders Standing Orders prn Orders Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 31

Professional Roles in Medication Administration § Parts of a Medication Order • • • Name of the client Date and time when the order is written Name of the drug to be administered Dosage Route by which it is to be administered and special directives about its administration • Time of administration and frequency • Signature of person writing the order Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 32

Medication Administration Record (MAR) § The MAR is a medical record form that contains the drug’s name, dose, route, and frequency of administration. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 33

Systems of Medication Measure § Metric System (Decimal System) § Apothecary System § Household

Metric System § Measurement Conversions within the Metric System • • Milligrams to grams Milliliters to liters Grams to milligrams Liters to milliliters Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 35

Systems of Medication Measure § Drug Dose Calculations • Several formulas are available to calculate drug doses for adults and children. • Pediatric Dosages - The nurse should realize that dosages are approximate and often need adjustment based on the child’s response. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 36

Medication Storage and Distribution § Narcotics and Controlled Substances • Federal regulations require recording of specific information for each drug administered. • Nurses count narcotics and controlled substances at specified intervals. • Narcotics and controlled substances are kept in double-locked storage. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 37

Medication Storage and Distribution § Narcotics and Controlled Substances • If a narcotic has to be discarded, a second person acts as a witness, and that person also signs the narcotic sheet. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 38

Narcotics and Controlled Substances § Drug Abuse in Health Care Professionals • State boards of nursing are developing impaired nurse programs for nurses with addictive behaviors and has increased the reporting of nurses with addiction problems. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 39

Safe Medication Administration § Interpretation of Medication Order • The nurse is responsible and held accountable for questioning any medication order if, in the nurse’s judgment, the order is unclear or in error. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 40

Safe Medication Administration § The “Five Rights” of Medication • • • Right medication Right dose Right client Right route Right time Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 41

Safe Medication Administration § Documentation of Medication Administration • The nurse responsible for administering the medication must document on the MAR the time the medication was given and initial it. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 42

Documentation of Medication Administration § If the client refuses to take a medication or was unable to take it, the nurse must indicate that a dose was missed and why. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 43

Safe Medication Administration § Medication Errors • Documented in a variance or incident report. • Health practitioner must be notified promptly. • Implementation of an organization-wide system for promoting safety and in identifying potential errors. • Clients and families are informed about outcomes of care including adverse events. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 44

Safe Medication Administration § Prevention of Medication Errors • Following the Five Rights and three checks • Correct dosage calculation • Documenting and knowing the client’s health and medication history • Not giving medications that have been removed from their unit dose package or drawn up in a syringe by anyone else Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 45

The Nursing Process in Medication Administration § Assessment • • Health History Medication History Physical Examination Diagnostic and Laboratory Data Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 46

Assessment § Medication History • • Allergies Prescription, Over-the-Counter Drugs Herbals and Alternative Therapies Biographical Data Pregnancy and Lactation Status Culture and Lifestyle Sensory and Cognitive Status Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 47

Nursing Diagnoses § Deficient Knowledge § Ineffective Therapeutic Regimen Management § Ineffective Health Maintenance § Impaired Physical Mobility Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 48

Nursing Diagnoses § § Disturbed Sensory Perception Impaired Swallowing Impaired Memory Noncompliance Copyright 2004

Outcome Identification § Client Education • Safe self-administration in the community setting - Purpose of the medications Adherence to schedule Self-monitoring for side effects Potential for interactions from over-the-counter medications Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 50

Planning § Ensures that clients receive medications at the appropriate time. § Ensures that medications that should not be given are withheld until their administration can be clarified with the health care practitioner. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 51

Planning § Adequate planning provides for questions and discussion by the client and demonstration

Implementation § Client Teaching • Written Medication Information - Scientifically accurate Unbiased in content and tone Sufficiently specific and comprehensive Presented in an understandable and legible format - Timely - Up-to-date and useful Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 53

Implementation § Administration of Medications • Diligence and concentration • In accordance with set procedures for each route • Additional specific guidelines for certain medications • Use of drug reference Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 54

Evaluation § The nurse is responsible for ongoing evaluation of client’s response to medication. § Nurses in the community setting need to evaluate the client’s ongoing ability to manage his or her medication regime. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 55

Medication Administration Procedures § Oral Administration • Client’s ability to take the medication as prescribed is assessed, including gag reflex, ability to swallow, state of consciousness, and presence of nausea and vomiting. • Client’s head must be raised to 90 degrees (high Fowler’s position). Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 56

Oral Administration § Sublingual and Buccal Administration • Use of Standard Precautions § Administration through Tubes • • Presence of bowel sounds Patency Residual Fowler’s or high Fowler’s position unless contraindicated Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 57

Parenteral Administration § Syringes • • 3, 5, and 10 cc standard syringes Insulin syringes vary in sizes Tuberculin syringes Prefilled single-dose syringes Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 58

Parenteral Administration § Needles • • • Basic parts Lengths and gauges Shaft Bevel

Parenteral Administration § Ampules • Glass containers of single-dose drugs § Vials • Single-dose or multiple-dose rubber-capped drug containers Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 60

Parenteral Administration § Intradermal Injection (ID) • • • Diagnose tuberculosis Identify allergens Administer local anesthetics Sites Dosage Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 61

Parenteral Administration § Subcutaneous Injection (SC, SQ) • Administration of insulin and heparin • Sites • Length of needle Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 62

Parenteral Administration § Intramuscular Injection • Promote rapid drug absorption. • Provide an alternate route when drug is irritating to subcutaneous tissue. • Sites • Gauge and needle length Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 63

Parenteral Administration § Intramuscular Injection • Air Lock Technique • Z-Track Technique Copyright 2004

Parenteral Administration § Intravenous Injections (IV) • Released immediately into the bloodstream. Copyright 2004

Parenteral Administration § Intravenous Injections (IV) • • • Assessment Check for Drug Incompatibility Methods of IV Administration Adding Drugs to IVs Administration by Intermittent Infusion Administering IV Push Medications Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 66

Topical Administration § Can provide a local or systemic effect. § Standard Precautions are

Topical Administration § Skin • Lotions, pastes, ointments, creams, powders, aerosol sprays, and patches • Relieve pruritus, protect the skin, prevent or treat an infection, provide local anesthesia, create a systemic effect. • Assessment for open lesions, rashes, erythema, skin breakdown Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 68

Topical Administration § Eye Medications (ophthalmic) • Drops, ointments, disks • Diagnostic and therapeutic purposes • Prevention of cross-contamination Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 69

Topical Administration § Ear Medications (otic) • Drops or irrigations • Soften ear wax, produce anesthesia, treat infection or inflammation, facilitate removal of a foreign body Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 70

Topical Administration § Nasal Medications • • • Drops or nebulizers (atomizer or aerosol) Shrink swollen mucous membranes. Loosen secretions and facilitate drainage. Treat infections of the nasal cavity or sinuses. Medical asepsis Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 71

Topical Administration § Respiratory Inhalant Medications • Produce fine droplets that are inhaled deep into the respiratory tract. • Produce anesthesia during surgery. • Treat respiratory diseases and symptoms. • Local and systemic effects • Devices Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 72

Topical Administration § Rectal Medications • Enemas, suppositories, ointments • Local and systemic conditions § Vaginal Medications • Suppositories, creams, gels, ointments, foams, douches • Treat inflammation, infections, discomfort, contraceptive measure Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 73