Chapter 35 Medication Administration Bonnie M Wivell MS

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

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

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

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 • Med. Watch 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

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

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

Patient Safety • To err is Human 7

Clinical Effectiveness of Safe Practices Intervention Results Physician computer order entry 81% reduction of medication errors Pharmacist rounding with team 66% reduction of preventable adverse drug events; 78% reduction of preventable adverse drug events Rapid response teams Cardiac arrests decreased by 15% Team training in labor and delivery 50% reduction in adverse outcomes in preterm deliveries Reconciling medication practices upon hospital discharge 90% reduction in medication errors Ventilator bundle protocol Ventilator-associated pneumonias decreased by 62%

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 Hydro. Diuril

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

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

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

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

Excretion • Medications are excreted through: – Kidney – Liver – Bowel – Lungs – Exocrine glands

Types of Medication Action Therapeutic effect: Side effect: Expected or predictable Predictable and often unavoidable Adverse effect: Toxic effect: Unintended, undesirable, and often unpredictable severe response Medication accumulates in the blood stream Idiosyncratic reaction: Allergic reaction: Over- or under-reaction to a medication Unpredictable response to a medication

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

Medication Dose Responses Serum half-life: Onset: Time for serum medication concentration to be halved Time it takes for a medication to produce a response Peak: Trough: Time at which a medication reaches its highest effective concentration Time at which drug is at its lowest amount in the serum Duration: Plateau: Time medication takes to produce a response Blood serum concentration is reached and maintained

Routes of Administration Oral Parenteral Swallow, Sublingual, Buccal ID, Sub-Q, IM, IV Other Topical Epidural, Intrathecal, Skin Intraosseous, Transdermal patch Intraperitoneal, Intrapleural, Instillation or irrigation Intraarterial Inhalation Intraocular Nasal passages, oral passage, ET or trach Insertion of disk containing med; drops

Effects of Nutrition on Drugs Grapefruit Vitamin K Can cause toxicity when taken with cisapride, carbamazepine, diazepam, verapamil, amiodarone, lovastatin Decrease effectiveness of warfarin In combination with MAOI meds Tyramine (found in (Nardil, Parnate, Marplan) cheese, beer, dried sausage, sauerkraut) creates increase in epinephrine HA, ↑ P, ↑ BP death Milk Interferes with absorption of tetracycline antibiotics

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

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)

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

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

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

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

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Medication Administration • • Pharmacist’s role Distribution system Medication errors (near miss) Medication Reconciliation – Verify – Clarify – Reconcile – Transmit • Nurse’s role 32

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

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.

Potential Medication Error

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

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

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

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

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

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

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

• Will cover actual administration and other issues surrounding administration during tomorrow’s class • QUESTIONS?