What is the time frame for passing a medication?
1 hour window to give meds 30 min before, 30 minutes after example- med is due @ 9AM- can give @ 8:30AM, 9:00AM or 9:30AM after 9:30AM it is late.
What are the 9 rights of medication administration?
Right Drug- Medication orders checked against medication label 3 times before giving. Consider if the drug is appropriate for the patient
Right Dose- Confirm the dosage is appropriate for age and size and within normal dosage range. Recheck math calculations.
Right Time- Check frequency medication is to be given, the last time it was given, when it’s to be given again.
Right Route/Form- Appropriateness of form being used. Make sure pt can take it in that route (PO vs NPO) If route is missing clarify with physician.
Right Patient- Check pt identity. Confirm name on the order and the pt. Use scanning bar on medication when possible.
Right Documentation- Information related to medication administration is cruicial to patient safety. Document after given- dose time route.
Right Reason- know the reason they are taking the medication- inform pt of reason
Right Response- drugs desired response. Continue to assess, monitor vital signs etc.
Right to refuse- (Patients refusal)
What is the nursing process for administering Medications?
Well established, research supported organizational framework for the practice of nursing.
Encompasses all steps taken by the nurse in caring for the patient (ADPIE)
The time required for half of an administered dose of drug to be eliminated by the body, or the time it takes for the blood level of a drug to be reduced by 50% (Pg 17)
The physiologic state in which the amount of drug removed via elimination is equal to the amount of drug absorbed with each dose. (Pg 18)
Steady state reached
Typically in 4-5 half lives of administered drug. Once steady state blood levels have been reached, there are consistent levels of dru in the body that correlate with maximum therapeutic benefits. (Pg 28)
absorption rates for Orally administered drugs
are absorbed from the intestinal lumen into the blood system and transported to the liver. Once in the liver, hepatic enzyme systems metabolize it and the remaining active ingredients are passed into the general circulation. Factors changed by amount of acid in the stomach, time of day medication administered, presence or absence of food/fluid, age, presence of other medications. Pg 21 First pass effect (Initial metabolism in the liver before drug reaches systemic circulation. Reduces bioavailability of the drug to less than 100% pg 21)
Absorption rate for enteric coated medications
designed to protect the stomach so dissolves in the intestines.
factors that affect the rate of absorption in parenteral route
fastest route by which a drug can be absorbed- general term meaning any route other than via GI tract. (pg 22) IV delivers the drug directly into blood circulation. IM and Sub-q are absorbed more slowly but still faster than oral. Are not first pass drugs. Absorbed more rapidly than orally. No gastric juices to break down. Sublingual- patients may swallow instead of allow to dissolve. Rectal- discomfort, absorbtion is erratic and unpredictable. Topical- skin needs to be clean and free of debris. Gloves help minimize contamination. Transdermal- rate of absorbtion is affected by perspiration, body temperature, patch can peel off. Inhalation- can be too rapid.
Drug receptor relationships: (Receptor is a reactive site on the surface or inside of a cell.)
Agonist: Drug binds to the receptor, there is a response
Partial Agonist: Drug binds to the receptor, the response is diminished compared with that elicited by an agonist
Antagonist: Druge binds to the receptor, there is no reponse. Drug prevents binding of agonists.
therapeutic range index
The length of time until the onset and peak of action and the duration of action play an important part in determining the peak level (Highest blood level of drug)
trough level (lowest blood level) If the peak level is too high then drug toxicity may occur. Which can be mild to severe. If the trough level is too low then the drug may not be at therapeutic levels to produce a response.
In Therapeutic drug monitoring peak and trough levels are measured to verify adequate drug exposure, maximize therapeutic effects, and minimize toxicity. (pg 27)
Additive effects: adding 2 drugs with similar effects added together to give same effect so smaller doses of each drug can be given.
Synergistic Effects: when 2 drugs are given together interact that their combined effects are greater than if they were given alone.
Antagonistic effects- when 2 drugs given together result in less than effect if the drugs were given separately.
Incompatibility: when 2 or more drugs are mixed together that diminish or kill the effect of one or both drugs. They must never be mixed and must be given at different times.
Tolerance: Decreasing response to repeated drug dose
Dependence: physiologic or psychological need for a drug.
Physical dependence: physiologic need for a drug to avoid physical withdrawal symptoms: tatachycardian an opioid addicted patient)
Psychological dependence: addiction, obsessive desire for the euphoric effects of a drug (pg 31)
Chemical name: Describes the drug’s chemical composition and molecular structure (2-acetoxybenzoic acid)
Generic Name: Name given by the United States Adopted Names Council (acetylsalicylic acid)
Trade Name: The drug has a registered trademark; use of the name is restricted by the drug’s patent owner (Aspirin)
Sequential processes of the pharmacokinetic phases
physical factors that interfere with PO absorption, of the different types of PO medications. (Pg. 21)
- Acid changes within the stomach, absorption changes in the intestines.
- The presence or absence of food and fluid.
- Portions of the small intestine removed because of disease (short bowel syndrome); similarly, bariatric weight loss reduces size of stomach.
common issues among older adults in prescribed drug regimens (Pg. 40)
More complicated medication regimens predispose older adults to self-medication errors (splitting their own tablets).
Lack of adequate patient education and understating of their drug regimens, and use of multiple prescribers and multiple pharmacies.
Adverse drug reactions (use of herbal remedies which can interact with prescription drugs).
Polypharmacy (multiple medications)
Nonadherence (pt’s want to adhere to medication regimen but cannot afford it)
hepatotoxicity and how you monitor it in labs and assessment (Pg. 41)
Assessed by testing the blood for liver enzymes such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT).
These lab values help asses the ability to metabolize and eliminate medications and can aid in anticipating the risk for toxicity and/or drug accumulation.
Lab assessments need to be conducted at least annually for preventative health monitoring and for screening possible toxic effects of drug therapy.
medications and medical conditions that require special considerations in the older adult.
See the purple box, table 3-4 on page 43.
medications and medical conditions that require special considerations in the older adult.
the Health Insurance Portability and Accountability Act (HIPPA)
the Controlled Substance Act
The Dietary Supplement Health and Education Act
The National Center for Complementary and Alternative Medicine
HIPPA (1996) requires all health care providers, health and life insurance companies, public health authorities, employers, and schools to maintain patient privacy regarding protected health information. Protected health information includes: patient health conditions, account numbers, prescription numbers, medications, and payment information. (P. 53)
The Controlled Substance Act requires the scheduling of every drug. There are five classes of drugs, designated from C-I to CV-. (P. 56)
The FDA is responsible for approving drugs for clinical safety and efficacy before they are brought to the market. The primary purpose of the FDA is to protect the patient and ensure drug effectiveness. (P. 54)
The Dietary Supplement Health and Education Act (1994), which requires manufacturers of such products at least to ensure their safety (although not necessarily their efficacy) and prohibits them from making any unsubstantiated claims in the product labeling. Ex. Can read “for depression” but not “known to cure depression’. (P. 54)
The function of the National Center for Complementary and Alternative Medicine is to conduct rigorous scientific studies of alternative medical treatments and to publish the data from such studies. (P. 54)
Nurses responsibility when educating a patient about medications
When educating a patient about medications, the nurse should use several modalities: explain, teach back, written materials. Make sure to assess the patient’s willingness and ability to learn. With written materials make sure that the patient can read at least the 8th grade level and that the print is big enough for the patient to see if they have any vision impairment. Make sure to address the specific needs of the patient. Speaking loudly or slowly will only serve to make the patient feel like you think they are not smart.
Assessment – Gather subjective and objective data. Be aware of verbal and non-verbal communication. Open-ended questions are encouraged. Assess level of anxiety. Physical needs that are not being met (pain, vomiting, etc.) become obstacles to learning, these issues need to be managed appropriately before any patient teaching occurs.
Diagnoses – A diagnoses of deficient knowledge refers to a situation in which the patient, caregiver, or significant other has a limited knowledge base or skills with regard to the medication or medication regimen. This diagnoses may also reflect decreased cognitive ability or impaired motor skill needed to perform self-medication. Noncompliance is another diagnoses, although it is usually the patients decision, you must asses the factors (lack of ability of the parent, family, or caregiver to administer the medication; etc)
Planning – This phase of the teaching-learning process occurs as soon as a learning need has been assessed and then identified in the patient, family or caregiver. The nurse and patient identify outcome criteria that are associated with the identified nursing diagnosis and are able to relate them to the specific medication the patient is taking. Ex. “patient safely self-administers the prescribed oral antidiabetic drug within a given time frame”
Implementation – This phase includes conveying specific information about the medication to the patient, family, or caregiver. Identify aids to help the patient in the safe administration of medications at home, such as the use of medication day or time calendars, pill reminder stickers, daily medication containers with alarms, etc. (read about this one its LONG)
Evaluation – This is a critical component of safe and effective drug administration. To verify success or lack of success of patient education, ask specific question. Adherence to medication is one key to determining where teaching was successful or not. Develop a new plan of teaching if teaching has failed.
What are all the elements of a medication prescription order?
2 patient identifiers (Name,DOB or MR #)
When a nurse administers the wrong medication, what actions should the nurse take and in what order?
Once the patient has been assessed and urgent safety issues have been addressed, report the error immediately to the appropriate prescriber and nursing management personnel, for example, the nurse manager or supervisor. (Pg. 67)
Administering medication to a baby less than 6 months
Mixing medications for infants should never go in the infant’s breastmilk or formula. Instead it should either be given directly via oral syringe or mixed with applesauce if the infant is > 6 months old (pg. 109)
correct way to administer a rectal suppository to an adult client
Assess patient for presence of active rectal bleeding or diarrhea, which generally are contraindications for the use of rectal suppositories. Don’t divide into smaller doses. Position patient on left side, unless contraindicated. Uppermost leg needs to be flexed toward the waist. Provide privacy and drape. Don’t insert the suppository into stool. Gently palpate the rectal wall for the presence of feces. If possible have the patient defecate. Remove wrapping form suppository, and lubricate the rounded tip with water-soluble gel. Insert the tip of the suppository into the rectum while having the patient take a deep breath and exhale through the mouth. With your gloved finger, quickly and gently insert the suppository into the rectum, alongside the rectal wall, at least 1 inch beyond the internal sphincter. Have patient remain lying on side for 15 to 20 minutes to allow absorption of medication. With children it may be necessary to gently but firmly hold the buttocks in place for 5-10 minutes until the urge to expel the suppository has passed. Older adults with loss of sphincter control may not be able to retain the suppository.
medication crushing protocol
When crushing medications make sure the medication is not on the “Do Not Crush” list. You should not crush: Enteric coated, capsules, SR, ER. When you crush multiple PO’s together there can be drug interactions, so crush one med at a time. (pg. 106)
protocol for administering an eye ointment medication
Gloves must be worn.
Make sure patient isn’t wearing contact lenses.
Assist the patient to a supine or sitting position.
Tilt the patient’s head back slightly. Remove any secretions with a sterile gauze pad…wipe from inner to outer.
Have patient tilt head slightly back and look up.
Pull the lower lid open to expose the conjunctival sac.
Drops: Hold dropper 1 to 2 cm above the conjunctival sac. Do not touch the tip of the dropper to the eye or with your fingers. Drop into the conjunctival sac…never apply eye drops to the cornea. If the drops land on the outer lid margins (if the patient moved or blinked) repeat the procedure.
Infants: Gently restrain head and place the drops at the corner near the nose where the eyelids meet.
Ointment: Squeeze medication along the border of the conjunctival sac. Start inner, move outer.
After: Ask patient to close eye gently, not squeeze or wipe eye. Warn patient vision might be blurry for a few minutes. If multiple eye drops are due at the same time wait for several minutes before administering the second drug.
liquid medication protocol
When preparing liquid medications, do not pour excessive medication back into the bottle.
The base of the meniscus should be right at the appropriate line on the medicine cup.
The cap of the medication bottle should be placed face up to avoid contamination.
The medication should be measured out in a calibrated oral syringe whenever possible.
ways to decrease pain at the injection site:
EMLA Cream: lidocaine 2.5% and prilocaine 2.5%
EMLA or a vapocoolant spray, if available, may be used before the injection to reduce the pain from the needle insertion. However, because these agents do not absorb down into the muscle, the child may still experience pain when the medication enters the muscle. Apply EMLA cream to the site at least 1 hour and up to 3 hours before the injection. Vapocoolant spray is applied to the site immediately before the injection. Another option is to apply a wrapped ice cube to the injection site for 1 minute before the injection. (pg. 122 Green Box)
anatomical landmarks for giving injections (pg 121-123)
Ventrogluteal site: (pictures 9-50-51-52)
Preferred site for adults and children. Considered the safest of all sites because the muscle is deep and away from major blood vessels and nerves. Position patient on side with knees bent and upper leg slightly ahead of the bottom leg. If necessary the patient may remain in a supine position. Palpate the greater trochanter at the head of the femur and the anterosuperior iliac spine. Place palm of your hand over the greater trochanter and your index finger on the anterosuperior iliac spine. Point your thumb toward the patient’s groin and fingers toward the patient’s head. Spread the middle finger back along the iliac crest, toward the buttocks, as much as possible. Injection site is the center of the triangle formed by your middle and index fingers. Give injection with your dominant hand.
Vastus Lateralis site: (pictures 9-53-54-55-56)
Generally well developed and not located near major nerves or blood vessels. Preferred site on injection of drugs such as immunizations for infants and small children. Patient may be sitting or lying supine, have the patient bend the knee of the leg in which the injection will be given. To find correct site place one hand above the knee and one hand below the greater trochanter of the femur. Locate the midline of the anterior thigh and the midline of the lateral side of the thigh. The injection site is located within the rectangular area.
Deltoid site: (pictures 9-57-58-59)
Easily accessible, but NOT the first choice for intramuscular injections because the muscle may not be well developed in some adults, and the site carries a risk for injury because the axillary nerve lies beneath the deltoid muscle. Also many nerves in the upper arm. Always check med admin policy because some institutions do not permit the use of the deltoid muscle for IM injections. The deltoid site must only be used for administration of immunizations to toddlers, older children, and adults and only for small volumes of medication (0.5-1 ml) Patient may be sitting or lying down, do not roll up tight fitting sleeves. Have patient relax arm and slightly bend the elbow. Palpate lower edge of the acromion process. This edge becomes the base of an imaginary triangle. Place three fingers below this edge. Find the point on the lateral arm in line with the axilla. The injection site will be in the center of this triangle, three finger widths (1-2 inches) below the acromion process.
What actions should a nurse take to prevent medication errors?
Assess lab results before giving the med
Verify the 9 Rights of medication administration
Only use approved abbreviations
Use the generic name for the medication but know the trade name (Trade name can have LASA issues)
protocol for Over the counter drugs and herbal remedies/dietary supplements:
When the patient is taking herbal supplements, always ask what prescription meds they are taking and evaluate for interaction
Johns Wort is not an approved treatment for depression
The major medical issues with herbal products are that they are not regulated by the FDA. Their safety is questionable since no one knows how pure they are, because of this you will have variances in effectiveness. They are low cost and readily available which is why they are attractive to the consumer.
Hepatotoxic Drugs: (Handout)
- Diabetes Mellitus medications
- Lipid lowering medications
- Protease inhibitors
- Heparin, Omeprazole, Halothane, Etretinate
Define Genetics (PG 97):
The study of the structure, function and inheritance of genes
Correct angle of needle insertion and correct syringe/needle size for SQ, IM, ID
SQ- 45 degrees, 5/8 to ¾ needle, 23-25 gauge
IM- 90 degrees, 1” to 2” needle, 23-25 gauge
ID- 15 degrees
How many ML in a teaspoon?
5 ML in 1 Teaspoon, 15 ML in 1 Tablespoon
Sublingual (SL) and Buccal medication administration (PG 106):
SL Medications must be dissolved under the tongue and no liquids for 30 minutes after the medication has dissolved, Saliva should not be swallowed until med has fully dissolved
Buccal medications must be placed in the cheek, alternate sides with each dose to avoid oral mucosa irritation.
Transdermal Patch Application (PG 134):
- Be sure the old patch is removed
- Clean the site of the old patch thoroughly and check for signs of skin irritation
- Rotate sides with each dose
- Need to be applied at the same time everyday
- Press the old patch together and wrap in the glove as it is removed, dispose in proper container
- Select new site for patch and make sure area is clean (free from hair, scratches or irritation) if hair needs to be removed, clip instead of shave to avoid irritation
- Remove backing from new patch, take care to not touch medicated side
- Place patch on skin site and press firmly around center and all edges, if an overlay is provided, place overlay on top of patch
- Instruct patient to not cut transdermal patches as it will release all the medication at once resulting in possible overdose.
Protocol for Intramuscular Injections:
The maximum amount of fluid that can be used in a single IM injection is 3 ML
Preferred injection site for immunizations in older children and adults is deltoid muscle