MEDICATION ADMINISTRATION Chapter 35 10262020 NRS 105 2011

MEDICATION ADMINISTRATION Chapter 35 10/26/2020 NRS 105 2011 1

6 Rights of Medication • • • Right Patient Right Drug Right Dose Right Route Right Time Right Documentation – if it wasn’t documented, it wasn’t done • #7 -THE RIGHT To REFUSE 10/26/2020 NRS 105 2011 2

The RIGHT Medication • As the physician prescribed? • Trade name or generic? • Does the drug match the MAR (medication administration record)? • Is the drug appropriate for the patient? • Does it make sense? 10/26/2020 NRS 105 2011 3

The RIGHT Dose • Does the dose of medication in your hand agree with the dose on the MAR? • Are the mg, mcg, m. L the same? • Is your math correct? • Double check!! 10/26/2020 NRS 105 2011 4

The RIGHT Patient • Have you checked using two patient identifiers? – Patient states…. . verifies DOB – Patient armband – compare to information on MAR – What if there is no arm band? 10/26/2020 NRS 105 2011 5

The RIGHT Time • • 10/26/2020 AM or PM Q 4 Tid Bid Qd HS NRS 105 2011 6

The RIGHT Route • • PO IV SC (SQ) TRANSDERMAL RECTAL IM Does it make sense? 10/26/2020 NRS 105 2011 7

RIGHT Documentation 10/26/2020 NRS 105. 320 W 2009 NRS 105 2011 8 8

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MOD – Medication on Demand • The Radio Frequency Identification (RFID) based wrist band • The first of its kind to be implemented successfully • Assists nurses by automating the process of administering patient medication 10/26/2020 NRS 105 2011 10

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ROUTES OF ADMINISTRATION • PO – Per Os/ by mouth • SL – Sublingual • Buccal • Inhaled • Intranasal • AD/AS/AU - Ears • OD/OS/OU – Intraocular [eyes] • Topical - Skin 10/26/2020 • • • IO - intraosseous PR – per rectum Vaginal IM - Intramuscular IV – Intravenous SC - Subcutaneous NRS 105 2011 12

SYSTEMS OF MEDICATION MEASUREMENT • METRIC SYSTEM – ml, mg, mcg, gm • HOUSEHOLD MEASUREMENTS – Tsp, gtts • APOTHECARY – Drams, grains • Know conversions/ carry table 10/26/2020 NRS 105 2011 13

ORAL ADMINISTRATION OF MEDICATION • SOLID FORMS – – – 10/26/2020 CAPLET CAPSULE TABLET GELCAP ENTERIC COATED NRS 105 2011 14

ORAL ADMINISTRATION OF MEDICATION • LIQUID FORMS – – – 10/26/2020 ELIXIR • CONTAINS ALCOHOL EITHER AS INGREDIANT OR FLAVORING EXTRACT • SEPARATE FROM BASE INGREDIENT • (VANILLA EXTRACT) AQUEOUS SOLUTION/ SUSPENSION • PARTICLES MIXED WITH BUT NOT DISSOLVED IN WATER SYRUP • MIXED WITH SUGAR AND WATER TINCTURE • MEDICINE IN ALCOHOL BASE NRS 105 2011 15

ORAL ADMINISTRATION OF MEDICATION • OTHER ORAL FORMS – TROCHE / LOZENGE • NOT MEANT TO BE SWALLOWED – AEROSOL • TOPICAL – SUSTAINED RELEASE 10/26/2020 NRS 105 2011 16

ORAL ADMINISTRATION 10/26/2020 NRS 105 2011 17

BUCCAL ADMINISTRATION OF MEDICATION • BETWEEN THE CHEEK AND GUMS – – 10/26/2020 TABLET SEMI-SOLID PASTE THICK LIQUID NRS 105 2011 18

SUBLINGUAL 10/26/2020 NRS 105 2011 19

TOPICAL APPLICATION • SPRAYS – – ORAL TOPICAL NASAL INHALED • Creams/ Ointments 10/26/2020 • VAGINAL/RECTAL – SUPPOSITORIES • EAR DROPS – POSITION EAR • EYE DROPS NRS 105 2011 20

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PARENTERAL ADMINISTRATION • • • 10/26/2020 INTRAMUSCULAR IM SUBCUTANEOUS SC INTRADERMAL [like TB test] INTRAVENOUS IV INTRAOSEOUS IO EPIDURAL INTRATHECAL (SUBARACHNOID SPACE) INTRAPERITONEAL INTRAPLEURAL INTRARTERIAL INTRARTICULAR [in a joint] NRS 105 2011 22

INTRAMUSCULAR • • PAIN MEDICATION ANTIBIOTICS VACCINATIONS SUPPLEMENTS – IRON – B 12 10/26/2020 NRS 105 2011 23

IM Injection Sites Ventrogluteal 10/26/2020 NRS 105 2011 24

Vastus Lateralis 10/26/2020 NRS 105 2011 25

Deltoid Injection 10/26/2020 NRS 105. 320 W 2009 NRS 105 2011 26

INJECTION ANGLES 10/26/2020 NRS 105 2011 27

Subcutaneous injection 10/26/2020 NRS 105 2011 28

Sub Q administration sites 10/26/2020 NRS 105 2011 29

Intradermal Injection 10/26/2020 NRS 105 2011 30

Syringes – NOT interchangeable 10/26/2020 NRS 105 2011 31

Sizes of Needles Length 3/8” to 3” Gauge 30 – 19 20 -22 G, 1 -1. 5” for IM 25 -30 G, 3/8 -1/2” for SQ 10/26/2020 NRS 105 2011 32

Nursing Roles • Legal and Ethical implications • Know your meds – Pharmacokinetics: • Because food, other drugs, disease, age affect absorption, distribution, metabolism, excretion – – – 10/26/2020 Actions Interactions Routes Measurement and Calculation, conversions Documentation NRS 105 2011 33

Responsibilities • • 10/26/2020 Prescribe – APN Correct drug and dose [range] Effects and implications Why med is ordered for pt Monitor effects – intended and other Reactions Education NRS 105 2011 34

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 10/26/2020 NRS 105 2011 35

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 10/26/2020 NRS 105 2011 36

Test Your Knowledge • The nurse is transcribing the physician’s orders for the newly admitted client’s medications. For which of the following orders would the nurse need clarification prior to administering the medication? A) Digoxin 0. 125 mg po daily B) Lasix 40 mg. po bid C) Tylenol 650 mg. po PRN D) Lipitor 20 mg. po at bedtime 10/26/2020 NRS 105 2011 37

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 10/26/2020 NRS 105 2011 38

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 10/26/2020 NRS 105 2011 39

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 is present Blood serum concentration is in concentration great reached and maintained enough to produce response 10/26/2020 NRS 105 2011 40

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 10/26/2020 Interferes with absorption of tetracycline antibiotics NRS 105 2011 41

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 10/26/2020 NRS 105 2011 42

Insulin Preparation • • Rapid, short, intermediate, and long acting Know onset, peak and duration (see page 743) ONLY regular insulin can be given IV Sliding scale based on blood glucose Gently roll cloudy DO NOT SHAKE Prepare last and administer first if mixed because regular can become “contaminated” and action can be affected – CLEAR to CLOUDY 10/26/2020 NRS 105 2011 43

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Drug Calculations Dose Ordered X amount = amount to dose on hand administer 1. Look at order + available concentration 2. Ballpark estimate 3. Calculate – paper + calculator 4. Check math, compare to estimate Convert to same units [mcg, mg] 10/26/2020 NRS 105 2011 45

Examples • • 1. 2. Order: Digoxin 12. 5 mg PO daily On hand: 25 mg tablets Change to same units if needed [mg= mg] Put in formula: 12. 5 X 1 tab = ? 25 amount to give 3. Estimate: 12. 5 is about ½ of 25 4. Solve: ½ X 1 = ½ tab 5. Check estimate – ½ = ½ 10/26/2020 NRS 105 2011 46

Wait! • You’re not done yet: • Nursing implications for Digoxin: – Assess and record apical HR and B/P – Hold for systolic B/P < 90, HR <60 – Know WHY – Know action of Digoxin – Document HR, B/P, dose given or held, time 10/26/2020 NRS 105 2011 47

Example 2 • Order: APAP gtts 5 mg/kg q 4° PO fever/pain • Available: 80 mg/0. 8 ml [= 100 mg/1 ml] • Wt is 3 kg • 5 mg X 3 kg = 15 mg dose • Estimate: 100 mg in 1 ml, dose is 15 mg; will be very small dose - < 1 ml 10/26/2020 NRS 105 2011 48

Solve 15 ml [ordered] X 1 ml = ? amount 100 mg [on hand] to give 15 mg/100 mg X 1 ml = 0. 15 ml Check – close to estimate? [if I mess up my math and get 1. 5 ml, estimate will catch me] Administer and document 10/26/2020 NRS 105 2011 49

PRACTICE • You CANNOT Practice medication calculations too much • KEY skill for success in school & practice • PRACTICE, PRACTICE • Know conversions, abbreviations 10/26/2020 NRS 105 2011 50

Abbreviations to Avoid • Trailing Zero e. g. 1. 0 ml [read as 10 ml] • Lack of leading zero e. g. . 1 mg [read as 1 mg] • X 3 D ? ? Three doses or three days? • Drug abbreviations Mg. SO 4 – [mag sulfate] – Read as Morphine Sulfate [MSO 4] • Similar Drug names – clarify [Norvasc/Norflex, Fosamax/ Flomax] • Handwritten Orders/ MARS – Always Clarify 10/26/2020 NRS 105 2011 51

Medication References • Book form – – In med room, on Pyxis • Electronic – – Available for PDA, Itouch, Iphone 10/26/2020 NRS 105 2011 52

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 10/26/2020 NRS 105 2011 53

Nursing Diagnoses • • • 10/26/2020 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 NRS 105 2011 54

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 10/26/2020 NRS 105 2011 55

Goals • Generally: safe administration, knowledge • Pt will demonstrate safe and effective technique for preparing sliding scale insulin based on blood sugar within 24 hours • Pt will correctly demonstrate subcutaneous insulin administration before discharge • Pt will verbalize understanding of side effects of prescribed medications after this teaching session 10/26/2020 NRS 105 2011 56

Goals, con’t • You must monitor a client’s response to meds on an on-going basis – Goal is not evaluated just once in practice – E. g. Pain is 3/10 in 30 minutes – good; keep checking • The goals of safe and effective med administration involve the client’s response to therapy and ability to assume responsibility for safe self-care 10/26/2020 NRS 105 2011 57

Interventions • Administer medications per orders • Assess need for PRN meds • Assess/monitor medication effects [side effects, desired effect, toxic effects] • Teach/ educate pt/family – – How to measure accurately – Administration [safety] – Side effects, when to call DR 10/26/2020 NRS 105 2011 58

Evaluation • Was goal met? Partially met? Not met? • Pt correctly calculates insulin [sliding scale] based on BG • Demonstrates safe preparation and administration • Verbalizes side effects • Asks for pain medication when pain 3/10 10/26/2020 NRS 105 2011 59

Revising Plan • 1. If short term goal was met, reinforce, continue, or reset goal [increase independence, etc] • 2. if partially met, reinforce teaching, promote safety, assess what is needed • 3. Goal not met? Assess why not, change method, add [pain med plus ice and rest] 10/26/2020 NRS 105 2011 60

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 – many drugs = interactions 10/26/2020 NRS 105 2011 61

Test Your Knowledge • The nurse is teaching a client how to prepare 10 units of regular and 5 units of NPH insulin for injection. In what order should the nurse instruct the client to do the following? A) Inject air into the regular insulin B) Inject air into the NPH insulin C) Withdraw the regular insulin D) Withdraw. NRS 105 the 2011 NPH insulin 10/26/2020 62

Intravenous Administration • Nurses administer meds IV in the following ways: – As mixtures within large volumes of IV fluids (Banana bag) – By injection of a bolus or small volume of med through an existing IV line or intermittent venous access (heparin lock/saline lock/buff cap) – By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line • You are responsible for reading more about this in your text as there may be questions on the HESI 10/26/2020 NRS 105 2011 63

Peripheral IV 10/26/2020 NRS 105 2011 64

IV Solution and Pump 10/26/2020 NRS 105 2011 65

Patient Controlled Analgesia (PCA) 10/26/2020 NRS 105 2011 66

Central Venous Catheters 10/26/2020 NRS 105 2011 67

Test Your Knowledge • If a client who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects which of the following? A) Sepsis B) Phlebitis C) Infiltration D) Fluid overload 10/26/2020 NRS 105 2011 68

IV Care • PICC lines, central lines should be marked – treated differently • Disinfect skin [surgically] prior to starting IV; otherwise medical asepsis • Scrub the hub 15 seconds each time • PICC – surgical asepsis for dressing changes • Central lines are conduits [like Foleys] – high infection risk 10/26/2020 NRS 105 2011 69