Chapter 35: Medication Administration

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Chapter 35 Medication Administration

• Bonnie M. Wivell, MS, RN, CNS

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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

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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

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Medication Legislation and Standards Contd.

• FDA enforces laws, and ensures all meds on the
  market undergo vigorous testing before being sold
  to the public
• MedWatch 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

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Medication Legislation and Standards Contd.

• 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 nurses
  professional functions and responsibilities
• NPAs are broad in scope and nature so as not to
  limit the nurses functional ability
• Health care agencies interpret the NPAs

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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

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Patient Safety

• Patient Safety
• To err is Human

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Clinical Effectiveness of Safe Practices 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
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Pharmacological Concepts

• Drug Names
• Generic becomes the official name listed in
  publications and is the name generally used
  throughout the drugs 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 HydroDiuril

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Pharmacological Concepts Contd.

• Classification
• The effect of the medication on a body system
• The symptoms the medication relieves
• The medications 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

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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

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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 cant 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

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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

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Excretion

• Medications are excreted through
• Kidney
• Liver
• Bowel
• Lungs
• Exocrine glands

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

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Medication Dose Responses
Serum half-life Time for serum medication concentration to be halved Onset Time it takes for a medication to produce a response
Peak Time at which a medication reaches its highest effective concentration Trough Time at which drug is at its lowest amount in the serum
Duration Time medication takes to produce a response Plateau Blood serum concentration is reached and maintained
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Routes of Administration
Oral Swallow, Sublingual, Buccal Parenteral ID, Sub-Q, IM, IV
Other Epidural, Intrathecal, Intraosseous, Intraperitoneal, Intrapleural, Intraarterial Topical Skin Transdermal patch Instillation or irrigation
Inhalation Nasal passages, oral passage, ET or trach Intraocular Insertion of disk containing med drops
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Effects of Nutrition on Drugs
Grapefruit Can cause toxicity when taken with cisapride, carbamazepine, diazepam, verapamil, amiodarone, lovastatin
Vitamin K Decrease effectiveness of warfarin
Tyramine (found in cheese, beer, dried sausage, sauerkraut) In combination with MAOI meds (Nardil, Parnate, Marplan) creates increase in epinephrine ? HA, ? P, ? BP ? death
Milk Interferes with absorption of tetracycline antibiotics
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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

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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)

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Prescribers Role

• Prescriber can be physician, nurse practitioner,
  or physicians 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

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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

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Communication of Medication Order

• Order is written on clients 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

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Components of Medication Orders

• Clients 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

• Pharmacists role
• Distribution system
• Medication errors (near miss)
• Medication Reconciliation
• Verify
• Clarify
• Reconcile
• Transmit
• Nurses role

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The Six Rights of Medication Administration

• Right medication
• Right dose
• Right patient
• Right route
• Right time
• Right documentation
• Right to refuse

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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.

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Potential Medication Error
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Critical Thinking

• Knowledge understand why you are giving a med
  if you dont know, look it up
• Experience skills become more refined
• Attitudes take adequate time to prepare and
  administer
• Standards ensure safe practice
• 6 Rights

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The Nursing Process and Med Administration

• Assessment
• Medical history
• Allergies
• Medication data
• Diet history
• Clients perceptual or coordination problems
• Clients current condition
• Clients attitude about medication use
• Clients knowledge and understanding of
  medication therapy
• Clients learning needs

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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

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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

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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

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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

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Evaluation

• You must monitor a clients response to meds on
  an on-going basis
• The goal of safe and effective med administration
  involves the clients 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

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• Will cover actual administration and other issues
  surrounding administration during tomorrows
  class
• QUESTIONS?