=> To a patient drugs can be:
-Potassium: heart contractility and electroconduction. Therapeutic range: when they're in the window. Life saving is it's low. Nitroglycerin is life-saving to increase diffusion. -Life threatening if you give a drug to lower cholestrol when you already have a low cholesterol!
- Process involving a chain of health care professionals: Prescriber, Physician or Dentist writes the order
- -1st chance to catch error: Physician Assistant or Nurse Practitioner
- -2nd chance to catch error:Pharmacy reviews and dispenses the order
- -3rd chance to catch error:Nursing reviews and administers the pharmaceutical to the patient: is the order appropriate? did pharmacy trascribe correctly? Is package of medicine correct?
- Registered Nurse (RN)
- -Licensed Vocational Nurse (LVN or LPN): can't give all drugs: IV push, not allowed to give any meds through IV but can give reg IV fluids.
- -In home setting, administration may be by individual, family member, or caregiver
- **Drug Nomenclature The chemical name: the pharmacological makeup of the drug
- The generic name: Usually a shortened version of the chemical name of the drug; usually lowercase
- The trade/brand name: naming of the drug by the pharmaceutical company; has registered trademark.
- ex: Lovenox: it goes in lovehandles and Lunesta (sleepiness)
**Processing Drugs Within the Body
-Absorption: Getting the pharmaceutical into the blood stream
-Distribution: Movement of the substance from the bloodstream into the tissues and fluids in the body From the point of entry. Mouth to stomach to absorbtion in GI to bloodstream to hepatic portal. "FIrst Pass Effect" through the liver, cuts down on the potency and dosage. IM injections absorbed locally into bloodstream (no breaking down) so it's distributed right away into capillaries and tissue. Therefore shots work better.
-Metabolism: Physical and chemical alterations (breakdown) that the pharmaceutical undergoes in the body; processing or using up of the medication, also includes breaking it down into waste products.
-Excretion: Eliminating waste products of drug metabolites from the body. Kidneys, stool from liver and skin "sweat out meds" like antibiotics. Matters with altered skin tissue (burns), or babies (larger porportion of skin to interior mass so excrete and absorb faster).
=> How quckly drugs work depends on these drugs.
=> The drug order
- Date written
- Time the order written
- Name of drug
- Route of administration
- Frequency of administration: Administration parameters
- Duration of administration
- Name of prescriber
-if anything missing: follow up with pharmacy or prescriber. Verbal update.
**Medication Administration Records (MAR)-
- => Identification: Patient nameDate of birthMedical record numberAccount number: tied with billing Allergies Height Weight BMI (Body Mass Index)sometimes creatine clearance
- -also discontinued info so you know if they have allergic reactions or still under the influence of the drugs because of a longer half life.
- => Medication: Name, Dosage, Time of administration, Date started, and Date discontinued
- Computer generated, Computerized
- => Licensed clinician administering medications: Initials of those administering medications (and time) and Signatures of clinicians administering medications (initial validation)
“Window” of drug administration:
60 minutes before and 60 minutes after of breakfast
=> Automatic STOP orders (specific to individual institution-check hospital policy and procedure) aka
- "falling off the MAR": the prescription just kept going and going, day after day and wind up dependent on it.
- Hypnotics=72 hours
- Narcotics=72 hours
- Anti-infectives=14 days (knock off natural flora or end up with C. Diff, danger kidneys and liver)
- Prophylactic post-operative anti-infectives = 24 hours.
- Person had sterile surgery and patient is getting anti infectives just in case, last dose must be done with in 24 hours after the surgery stop time. After skin is completely closed and official surgery end time is documented, post antiinfective must be done within 24 hours. THis means sometimes they don't get their antibiotic x3 doses becaues of weird timing. All others including IV fluids=30 days (multivitamins, -Laxatives..BP stuff)
- -> If longer than the stop order, the prescriber (NOT THE NURSE) must document why.
=> Parenteral Routes-
- Means does not pass through the first effects of the liver.
- Sublingual (SL): Mucous membrane absorption, capillaries right under tongue.
- Intravenous (IV)
- Intramuscular (IM)
- Subcutaneous (SQ or SC)
- Intradermal (ID)
- Intracardiac, Intraspinal, Intracapsular (none of which we do)
- Epidural: we manage, but we don't start.
- Topical - absorbed through skin then directly into blood stream.
- *Buccal vs Sublingual: difference in dissolve rates where sublingual should be faster.
- Injection into a muscle
- Needle at 90 degrees
- Z-track method
- 21-25 gauge, 5/8-1.5 inches
- Change needles after withdrawing fluid from a vial
- Use filter needle for ampules (never inject with a filter needle)
- No more than 3ml of fluid
- 2ml maximum for deltoid
- Aspirate syringe to check for blood
- IM sites: Dorsal gluteal, Ventro gluteal, Deltoid, Vastus lateralis
- Injected into the fatty (subcutaneous) layer of skin
- Needle and syringe at a 45- 90 degree angle
- 24-27 gauge; 3/8 to 5/8 inch
- No more than 1ml of medication
- Use insulin syringe for insulin only (calibrated in 50-100 units)
- Use Tuberculin (TB) syringe for all other SQ meds (calibrated in hundredths)
- Administered into the skin (between dermis and epidermal layers) on the inner surface of the lower arm
- Used for allergy testing, Tuberculosis, etc
- 0.1-0.2ml is injected close to the surface to form a wheal or bubble
- Use a TB syringe: “bevel up” technique
-> IV push: A small volume of drug injected through a syringe into the bloodstream, we don't do this until NS 4. DIRECTLY: No going back, systemic, very serious! If you made a mistake in calc, in drawing it up or infive rights.. you can harm someone.
-> IV infusion: A large volume of fluid, with or without drugs added, which infuses continually into a vein; larger IV bags, mostly fluid sometimes meds. You set up and infuse, not insert until NS 4
-> IV piggyback: 50-250ml of fluid volume to dilute ordered medication dose. Used for intermittent infusion at specified intervals; smaller bags, intermittenly (given now), runs half an hour and leave bag empty because safer to keep the system closed. Should be left hanging there to avoid infection.
** Needle Safety
- Safety is #1 priority
- OSHA driven standards to protect health care workersNeedleless systems: in order to access IV, you dont' need a needle anymore. It's one of those push and screw things with plastic tips. Needle is required to have a sheath on it.
- Needle guard: tiny cork thing used in srugical areas used in procedure kits
- -epidural and spinal need.
- => Sharps container: ONLY sharps go into here. No gauze, gloves, alcohol pads...
- -Disposed after full line, snap it shut so it doesn't overfill and sharps poke at the top. Gets autoclaved then incinerated into powder, or filled with plaster and goes into cement.
- => Needle stick/blood borne pathogen exposure protocol
- -involves paperwork, go to employee health, gets blood drawn for blood borne pathogens and depending on how bad their exposure was, they get their blood drawn at 6 weeks and then 6 months. to see if they suddenly come up with something. Get offered Prophylactic meds based on the exposure that they've had. Educated on the variety of blood borne pathogens on the floor and the possible prophylactic meds and the degree of risk with each and let the person choose.
=> Lotion, cream, ointment, transdermal patchIndications: Protect skin, prevent dryness, treat itching, relieve pain, and pharmacokinesis
- => Procedure
- Cleanse skin ahead of time, natural body oils will block absorption of medication. Dry skin. Apply (medicated) lotion with gloves and rub into skin unless otherwise indicated not to (example: nitropaste-just to sit on skin with a cover patch on it, no rubbing in.) Don't touch nitropaste! It'll cause super red, warm hands and vasodilation through skin and eventually faint. Now it's in a sqeeze dose package. Measure finger tip unit (FTU)
- Remove and apply all transdermal patches with gloves (there still may be some residue) Dispose of transdermals in pharmacy waste or sharps containers (people will dig and taste the patch? o.0)
- **Finger Tip Units (FTU): Approximate number of FTU for various body areas
- Body region FTU
- Face/neck 2 1/2
- Trunk 14
- Arm 3
- Hand 1
- Groin 1
- Leg 6
- Foot 2
=> Eye Medications
- Pt must lie down or sit with head tilted back, go for conjuctival sac
- Wear gloves
- Pull lower eye lid down and place drop in the lower conjunctival sac (prevents cornea exposure)
- Press gently on medial nasolacrimal duct to prevent systemic absorption so it doesn't go systemic. If you don't press on it, it'll go through into duct and go into the sinuses and into nose.Use tissue to blot excess med
=> Eye Ointment
- -> Procedure
- Patient must lie down or sit with head tilted back
- Wear gloves
- Pull down lower lid to expose conjunctival sac and place a ribbon of med in this area, from inner to outer cantus. ("ribbon of ointment out of tube, get them to blink, usually they're not fully conscious)
- Instruct patient to close eyes for 2-3 minutes; Vision will be blurry
=> Administering Ear Medication
- Prescribed to soften ear wax, treat infection, anesthetic effect, and to immobilize insects:
- Patient should be sitting
Adult: Pull auricle up and back
Child: Pull auricle down and back, "there's no u"
=> Nasal Medications
- Used to achieve local effects on the nasal mucosa, indirect effects on the sinuses, or a systemic effect (like calcitonin: to alter hormones to stop osteoporosis):Migraine headaches
- Nicotine suppression
- -> Procedure
- Sit, head slight tilted back
- Insert tip into nose—occlude other nostril
- Inhale and squeeze medication
- Repeat in other nostril if ordered (only)
- SE: irritation, headaches,
- -don't blow your nose afterwards, maybe 10 minutes. You can blot.
- Metered-dose inhaler (MDI): tend to be powder
Nebulizer (med/neb): masks or pipes
- Nasal inhaler: without spray, stick in nose and you breath in from it.
- -canisters have dosing. Often times poweders.
- =>Procedure-If it has propellant, you need to shake it. It'll look like aerosol can, and it'll say, "shake well"Plastic holder --- shake canister ---breath out
- Breath deeply as the medication is depressed
- Hold breath for few seconds—exhale, "purse lipped breath out"
- Wait 1-2 min between doses—clean mouthpiece-there's also spacers, squeeze the accuator. makes a noise if you breathe too fast.
- Rinse mouth after dose: imporatnt with corticosteroids (immunosuppressant, alters normal flora in mouth causing candida/thrush in mouth making tongue sore), rinsing helps with there's no breakdown in skin of the mouth and no absorption in mouth.
=> Nasogastric (NG) Tube Med Administration(also gastric tubes)
- *ATI: Flush with 10-30 mL to clear tube before and after meal.
- Meds must be crushed and mixed with liquid (H2O-normal drinking water, Sterile Water, or juice)Assess placement of Nasogastric tube (NG) BEFORE FLUSHING WITH WATER and MEDS. Could be in lungs or pointing out of mouth. Put continuous nutrition (if indicated) on hold
- Aspirate for residual (note total residual amount) if it's stomach. If J tube (small intestine) no need to check for residual because there's no fluid. Anatomically impossible. ONLY GASTRIC. PEG J - jejunum tubes do not require aspiration
- -Too much residual: change feeding, hold the meds (because stomach is already full). Pulling residual until it stops. Use clean gradual container, take all residual out into container. Put BACK into stomach up to the facility limit. (If you pull out a total of 200, then put in back 100 if that's the hospital limit). Instill residual volume while listening with stethoscope in epigastric area
Prepare medications: Crush and wait to Dissolve. NOTE. YOU CANT CRUST ENTERIC COATED OR EXTENDED RELEASE, "XL". Protonix is XR. But Digoxin is fine to crush.
- => By Gravity: Attach 60 cc syringe to N/G tube without plunger and instill fluid flush, then the meds followed by enough liquid to clear the meds of the tubing (gravity method)
- -Clamp N/G tube (if on suction, or if meds require absorption on empty stomach) after medication administration or resume continuous feeding ("After getting medications in and flushing tube, you need to clamp the tube. If they're getting feeding continuously, restart the feeding. If they were previously suctioned, and you are allowed to give meds then you have to clamp the tube for like an hour to allow meds to be absorbed and move down into intestines before turning suction back immediately cos there goes all your meds!")
- -residual volume (not part of output because that's what you got, that's just what you found, unless you did discard it)
- -total fluid volume administered on intake record!!
Provides both local and systemic effect
Most common are laxatives, antiemetics, and antipyretics, also pain meds sometimes
Left side-lying Sims’ position: that's the way rectum curves into sigmoid colon
Place bed protector (chuck) under pt. bottomWear glovesLubricate medication with water soluble lubricant (vs petroleum or oil because it seals off the suppositories and resists the absorbtion)
- Administer past 1st rectal sphincter valve: Some people have rectal tone, insert and feel rectal sphincter around your finger so you know it's deep enough. Remain in side lying position for 15-30 minutes: if whole suppositories comes out, then get another one (unless it's to induce a BM)
- Keep bedpan or bedside commode readily available
- local infections of vaginal canal, pruritus, irritations, Generally used to treat infections, irritations, or pruritis requiring topical treatment
- Dispensed in:
- Foams, jellies or irrigations
- Side-lying Sims’ position
- May use frog-leg supine position (lithotomy)-mostly outpatient.
**Patient-controlled Analgesia (PCA)
-PCA is a method to relieve pain through self-administration of analgesics; PATIENT CONTROLLED ONLY; up to them to administer medications to themselves, the Nurse CANNOT press it nor the family. they must be cognitively aware (no dementia or overly sedated). the nurse must STILL assess.
- -Programmable pump by RN: using dose (pressing button)
- -Basal rate = continuous hourly dose; get little meds dripped into them every hour witout pressing buttom; oversedated so pulse oximeter to see they're not.
- Bolus dose = dose prescribed for breakthrough pain (administered by RN).SQ, IV or epidural; typically IV. Safety lock-out interval: so person can't continually keep pressing the button over and over again. Thre's a history of how many times they've pressed the button. Minutes between doses.Once it reached hourly limit, it beeps.
- -narcan for anyone who has PCA
-Historically used for chronic intractable pain, and chemotherapy (especially for cerebral/spinal cancer area), labor/delivery
-Used in Obstetrics for Cesarean Section
-Management of postoperative pain: spinal anal for surgery and epidural to manage immediate post operative pain.
- -Opioids through there or anesthetics- as student nurses, we CANNOT take opiods (fentanyls) narcotic protocol: too much risk. You must check on them every 15 mins and head to toe every hour. But anesthetics (lidocaines) are fine.
- -assessment variations: Limited ROM, decreased strenght, paralyzed state, slowed GU, might have foley, check area for infection, area for Cerebral spinofluid leakage and check for spinal headache. NPO for this because if they bloat, gastric system shuts down.
**Managing Controlled Substances
- Controlled Substance
- Identified by the Drug Enforcement Agency (DEA) as having potential for abuse by humans
- Identified by a capital “C” and Roman numerals (IV) on the label
- Categorized according to their abuse potentialCategories are known as schedulesSchedule is I through IV with I begin most addictive and IV being the least addictive
- -Schedule 1: cocaine, heroine.
- -Schedule 4: Lyrica Narcotics must be stored, accounted for, and distributed according to strict legal guidelines.All narcotics are recorded on a narcotics sheet or electronic dispensing system (PYXUS: computer attached to a dispensing system, Accudose) and the record must match what is on hand at all times.Keys to narcotics are carried by a Registered Nurse and the keys never leave the unit
- Electronic dispensing system uses a “fingerprint” or personal PIN # of the Registered Nurse to gain access into the system
- Any wasted narcotics must be co-signed by 2 Licensed clinicians (LVN OR RN, no cna's!).
pt not wanting them, don't use it all, had to cut it, only draw up part of it, expiration is badAbuse or misuse of controlled substances can cause you to lose your license as a Registered Nurse
**Nursing Responsibilities: Med Administration
Know the 5 R’s and make them a routine in your nursing practice every single time
Administer medications prepared only by you!!
Know medication purpose, method of action, side effects, safe dose range, system of metabolism, and safety precautions
Evaluate client response to medications
Reassess pain 30 minutes after pain med given (depends on route)
Reassess system specific effectiveness based on drug onset of action: know parameters but also take your patien't s/s into consideration. If they look hypoglycemic, don't give them hypoglycemia meds despite their vitals looking normal
NEVER leave or store medication at client’s bedside
Review medications at the bedside with your client
Check:Allergies, Expiration dates, Vital signs, Labs pertinent to medication
**Administration NG tube Medications
NG Tube Medication Administration
Assess if the dispensed medication can be crushed or dissolved
Apply clean gloves
Assess Abdomen: Inspect, Auscultate (confirm placement), Percuss, and PalpateAssess respiratory status
Elevate HOB greater than 30 degrees
Dissolve crushed medication in warm tap water; Use sterile H20 if pt is immuno-compromised
Clamp tube and turn off feeding if necessary Note: Some meds require feeding to be off 30 minutes prior to and after administration. Refer to your drug guide (nursing considerations)
Attach 60cc syringe to NG tube portUnclamp tube
Pour dissolved medication into syringe
Allow to administer by gravity
Follow with 30-50cc H20 (at room temperature).
Clamp tubeRemove syringe
- Attach feeding
- Unclamp tube
- Turn on feeding
**SUBCUTANEOUS INJECTIONS (INSULINS)Assessment:
- Check physician order
- Review each drug to be given, onset of action, peak of action, and contraindications
- Assess clients physical condition, V/S, Labs,
- Assess condition of potential injection site
- No lesions or scars!! (no circulation so no absorbtionCirculation status (Cap refill)Site of last dose given so you can rotate!Assess current allergies,
- Assess age, Assess client’s knowledge base about the use of medications
- => GoalsThe client will remain comfortable during administration The client will experience no allergic reaction or adverse side effects The client will verbalize understanding of the medication
- Purpose/ActionAdverse Reactions
- The client’s privacy will be maintained during administration
=>ImplementationObtain MAR (Medication Administration Record)Wash handsUnlock medication cart or log onto computer dispensing systemGather suppliesMedication vial or ampouleTB syringe or insulin syringeAlcohol prep padsBand AidPrepare medication using the 5 Rights: Right Patient, Right Med, Right Time, Right Dose, Right Route, documentation & educationCheck expiration date on all medications
- => ADMINSTERING:
- DOUBLE CHECK ALL prepared meds with MAR, and licensed personnel (insulin and injectable anticoagulants!!)
- Place client in a comfortable, and private position
- Select and prepare injection site
- Apply gloves
- Wipe area to be injected with alcohol swab in a circular motion and allow to dry
- Administer medications to client using the 5 rights: Right Patient, Right Med, Right Time, Right Dose, Right Route, documentation & education
- Explain the purpose and adverse reactions of the drug and answer any questions
- Pinch skin with non-dominate hand
- Quickly and firmly, in a dart like manner, inject needle into skin
- Release skin and aspirate (never aspirate insulins or anticoagulants)
- Slowly inject the medication
- Withdraw needle and apply gentle pressure to site with swab
- Cover with band aid
- Dispose of soiled supplies
- Reposition client for comfort
- Remove gloves and wash hands
- Document procedure complete
Injectable Medication (ID)
- All Injectables:Use correct size needle (gauge/length) based on viscosity of fluid, parental method, anatomical location of injection, and size of patient.ALWAYS WEAR GLOVES!
- Bevel of needle must face up
- 5-15° angle of insertion
- Do not aspirateInjectable Medication
- DO NOT aspirate insulin and anticoagulants
- ASPIRATE all others
- DO NOT rub anticoagulants
- 45-90° angle of insertion
- Dependent upon amount of skin pinched
When mixing, withdraw clear (short acting) to cloudy (long acting)
NEVER EVER mix Lantus with any other insulin
ALWAYS, ALWAYS, ALWAYS use insulin syringe for insulin
Obtain correct syringe size
Injectable Medication (IM) Administration Tips
- ALWAYS aspirate
- Use one hand method
- 90° angle of insertion
- Dart-like manner
- 3ml maximum
- 1-2 ml maximum for deltoid
- ALWAYS change needles if withdrawing fluid from a vial
- ALWAYS use filter needle when withdrawing fluid from an ampoule
- Z-trackUtilize this method for fluids that can stain or are irritating to the dermal layers :Vitamin B Demerol
Primary Intravenous Fluid Administration Tips
- Know the rate of infusion (hourly rate)Know the drip (gtt) rate
- Anticipate when new IV bag is due to be hung
- Know when the IV was insertedKnow the size (gauge) of IV inserted in your patient
- Know if IV fluids infusing into the same line are compatible
- Once an IV bag has been spiked (tubing inserted), the bag can hang for NO MORE than 24 hours
- ALL IV tubing and solutions must have date/time they were hung documented on the tubing/fluid bag
PRIMARY fluid and IVPB tubing can be used for no more than 72 hours
TPN, and Lipid tubing can be used for no more than 24 hours
IV tubing used for any iron products can be used for only ONE dose, then must be discarded
NG/G Tube Medication Administration Tips
Always wear clean gloves
- Check Residual and Placement before administration of medication
- Check medication compatibilities
- Check if medication must be administered on empty stomach
- Check if ok to crush medications
- Obtain clean graduate container and 60 mL cath-tip syringe every am and label with date and time
- Know if can use tap H20, or must use sterile H20 (room temperature)
- Keep HOB elevated >30 degrees at all times
- Use gravity technique (H20-meds-H20)
- Turn off suction if NGT is on suction and resume suction in 1 hour
- Document amount of fluid used for flushing and administration on Intake record
Discard residual feeding contents
- Crush EC, XL, SR, or TR tablets
- Use hot or cold water for medication administration