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Drugs and Medications
· Any substance that modifies body function when taken into the body
Any substance that modifies body function when taken into the body
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Drug nomenclature:
- · Chemical name – identifies drug’s atomic and molecular structure
- · Generic name – assigned by the manufacturer that first develops the drug, non proprietary ex: acetemenophin
- · Official name – name by which the drug is identified in official publications USP and NF
- · Trade name - brand name copyrighted by the company that sells the drug, proprietary name ex: Tylenol, 17 years = 10 years for research, 7 years on market
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Categories of Medications:
- Prescription-NP, Dr. licensed personnel
- · Nonprescription-Zantac, be careful, can do damage if you mix with prescription
- · Dietary and Herbal Supplements-again, be careful, no control from FDA
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Nursing Concepts of Medication Administration
- · Knowledge
- · Experience
- · Attitudes
- · Accountability and responsibility
- · Standards of care
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Medication Knowledge:
- · Nursing Implications and Assessments Before/After Administration
- · Name of Medication (Generic/Trade Names)
- · Classification-general category, pharmacological (broad description)and therapeutical (tells how drug works)
- · Action/Desired Effects
- · Dosage and Safe Range
- · Route of Administration
- · Side Effects/Adverse Reactions
- · Drug Interactions
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Patient Knowledge:
- · Medication History (Taylor p. 786, Focused Assessment Guide)-can get a pretty good picture just by looking at the meds being taken.
- · Current and Past Illnesses
- · Patient’s Health Status
- · Laboratory Test Results
- · Known Drug Allergies-what was the problem?
- · Patient Assessment is Ongoing
- · Before, during, and after Medication Administration
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Medication Orders:
- · No medication may be given without a written medication order from a licensed practitioner
- · Physician Order Form – Hand Written
- · Computer-generated Pharmacy Order-can receive by fax
- · Computer Prescriber Order Entry (CPOE)-more clear because handwriting is not involved
- · Verbal Orders
- · Phone Orders
Nursing students are not allowed to take verbal or phone orders.
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Types of Medication Order
- · Routine or Standing Order - ongoing prescription to be administered until discontinued by physician, each floor may have their own.
- · P.R.N. Order - prescription to be administered when necessary for a specified problem or condition
- · Single or One-time Order - prescription to be administered only once, not necessarily for an emergency
- · STAT Order – prescription to be administered immediately; frequently for an emergency situation
- · Standing Protocol Order – prescription written for use in specific situation
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Seven parts of order:
- · Patient’s Name - full name and ID number
- · Date and Time - when the order is written
- · Name of Drug - to be administered
- · Dosage of the Drug
- · Route by which the drug is to be administered (Taylor p. 780,Table 29-2)
- o Oral
- o Parenteral
- o Topical
- o Pulmonary
- · Frequency of Administration – time and frequency stated in standard abbreviations
- o a.c. and p.c. drugs - depends on the time that meals are served
- o Pre-op and STAT orders administered at the designated hour
- · Signature of person writing the order – including their title (prescriber)
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Checking Medications Orders:
- · Medication orders are copied onto patient’s MAR or CMAR
- · Nurse is responsible for checking:
- o Medication Order was transcribed correctly by comparing it to the original order
- o 7 parts of the medication order are present for each medication that has been ordered
- o Dose of medication is appropriate
- o Medication is appropriate for patient
- o Patient is not allergic to medication ordered
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Medication Administration Record
- · Legal document – handwritten or computerized
- · Patient’s full name, date of birth, allergies, and room number
- · Scheduled, unscheduled, discontinued medications
- · Medication name, dosage, route, frequency & time of administration
- · Parameters for administration of medication-always initial if you didn't give
- · Order date, start date, end date
- · Nurse’s signature and initials
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Questioning Medication Orders
- · Nurses are legally responsible for all drugs they administer, therefore:
- o always know what you are giving and why
- o drug allergies should be clearly labeled – question orders that may be inadvertently prescribed
- o question any drug order suspected to be in error with the person who wrote the order (prescriber)
- o never guess what an order may read
- · Nurses have the right to refuse to administer any medication that may be harmful to a patient
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Types of Medication Distribution Systems
- · Stock Supply-not seen so much anymore, pain meds, Tylenol in a bottle
- · Unit-Dose-individually packed
- · Individual Supply-long term care, two weeks at a time
- · Computerized Automated Dispensing Cabinet (ADC)-right drawer automatically opens, don’t put peds and similarly named drugs next to each other. Follow policy.
- · Medication Cart- little pods with enough drawers for all your patients. privacy screens need to be used.
- · Bar Code System-you are scanning your badge, then your patient
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Safe Medication Administration:
Errors can cause 150 deaths per day
- · Accurate medication order and MAR/CMAR-
- · Accurate patient identification
- · Accurate verification of patient’s drug allergies
- · Accurate drug calculation
- · Accurate administration of medication using the 5 Rights and 3 Checks
- · Accurate patient assessment and explanation
- · Accurate documentation
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Accurate Medication Order and MAR/CMAR
- · Patient’s Name, Date of Birth
- · Check each drug in the order they appear on the MAR/CMAR - always read from the top to the bottom of the MAR/CMAR
- · Do Not Skip Around!
- · Verify that the drugs transcribed in the MAR or CMAR are correct by comparing them with the original physician order
- · Question orders with the prescriber
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Patient Identification:
- · all patients must wear a legible identification bracelet (ID band)
- · identify the patient by examining the identification bracelet
- · ask patient to state their full name and one other identifier (date of birth) If he can't reply ask another nurse on the floor.
- · compare with MAR/CMAR for confirmation of name and date of birth
- · staff can assist in identifying confused or nonverbal patients
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Verification Drug Allergies:
- · Check the patient’s medical record for any drug allergies
- o All drug allergies must be clearly identified on the MAR or CMAR
- · Verify that patient is not allergic to any medications to be administered
- · Beware of patients allergic to a class of drugs
- o Tetracyclines – tetracycline, doxycycline, minocycline
- o Cephalosporins – many – refer to Davis Drug Guide
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Accurate Dose Calculation:
· Drugs may not be packaged in the needed amount – BE PREPARED TO DO DRUG CALCULATIONS
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7 rights of administerng medication:
- The Right:
- 1. drug
- 2. dose
- 3. time
- 4. patient
- 5. route
- Additional Rights
- 6. reason
- 7. documentation
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The Three Safety Checks
· Drug label should be read 3 times during preparation
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When do you do the three checks? (Check for 5 rights)
- · Check 1: when you reach for the container or unit dosage package (Check each drug in the order they appear on the MAR)
- · Check 2: recheck each unit dose medication with the MAR as you place in the medication cup - do not open packet until at the bedside
- · Check 3: recheck each drug with the MAR at the patients bedside prior to administration
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Accurate Patient Assessment and Explanation:
- · Have you done all necessary assessments prior to giving the medication?
- · Have you explained to the patient what they are receiving?
- · Have you done all necessary follow-up assessments?
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Accurate Documentation:
- · Medication record is a legal document
- · Record administration of medications immediately after they are given, especially STAT doses, never before
- · Always done by the person who administered the medication
- · Keep empty drug packet(s) with MAR as you sign for the medication as back up
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Accurate Documentation:
- · Report and record drugs that were not given
- · MAR – nurse’s initials recorded; full name and title are recorded for identification of initials
- · CMAR – electronic signature attached to each medication administered
- · Patient assessments – apical pulse, BP
- · If patient on I & O, record amount of fluid taken with the medication
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Correct administration process:
- · Locate MAR – see what you will be giving – do any prior assessment that is needed (HR, BP)
- · Check patient drug allergies
- · Starting at the top - remove 1st medication – Do 1st check / 5 rights – set aside
- · Continue above until all medications have been removed
- · Do 2nd check – place unopened medications into cup
- · Take medications, MAR, and necessary equipment to patient’s bedside
- · Check patient identification using 2 identifiers
- · Do 3rd check at the bedside prior to administration
- · Administer medications
- · Document
- · Follow up with any necessary assessment
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General Safety Measures:
- · wash hands before preparing medications
- · do not pour drugs into your hand
- · prepare medications with good lighting and in quiet environment
- · nurse should work alone to avoid distractions and interruption
- · prepared medications should never be left unattended
- · prepare medications for only one patient at a time
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General Safety measures:
- · do not give medications poured by another staff member
- · do not pour drugs from containers with labels that are difficult to read or are partially removed or have fallen off
- · stay with the patient until all medications are taken (never leave drugs at the bedside or with visitors or other staff to give)
- · discard unused portions of drugs in the sink or toilet, never in a trash can
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General Safety Measures:
- · medication cart or drawer should be kept locked when not in use
- · do not use drugs that have sediment, are discolored or are cloudy (and should not be)
- · do not give the drug if the patient states it is different from the one they have been receiving (verify drug first)
- · do not transfer drugs from one container to another
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General Safety Measures:
- · remember to check the expiration date of the medications you are preparing
- · you have a 1 hour window – ½ hour before the scheduled time to ½ hour after
- · Example: an 0800 med may be given as early as 0730 and as late as 0830
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REMEMBER!!!
- · The nurse who prepares the medication
- · Is the nurse who administers the medication
- · Is the nurse who documents the medication
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Medication Refusal
- · Determine WHY
- · Educate patient about medication
- · Patient’s have the right to refuse
- · Report to physician
- · Document !!!
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NPO
- · Nothing by mouth”
- · May be ordered “except meds” or “except meds with small amount of water”
- · Consider alternative routes especially for certain medications
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Holding Ordered Medication:
- · Written parameters for medication on MAR
- · Prudent nursing assessment
- · NPO status
- · Suspected allergy
- · Document omitted medication and reason - Requires circled initials on written MAR
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Medication Reconciliation
- · Process of obtaining an accurate list of the patient’s current medications
- · Medication list is compared with those ordered for the patient to avoid medication errors such as duplications, omissions, dosing errors, or drug interactions
- · Medications must be reconciled upon:
- o Admission
- o Transfer to another setting or level of care
- o After surgery
- o Discharge
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Medication Error:
- · Any preventable inappropriate use of medications
- · Any event that could cause or lead to a patient receiving inappropriate medication therapy or failing to receive appropriate medication therapy
- · May or may not cause harm
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Common medication orders:
- · Inappropriate prescribing of the drug
- · Extra, omitted, or wrong dose
- · Administration of a medication to the wrong patient
- · Administration of a drug by the wrong route or rate
- · Failure to give medication within prescribed time interval
- · Incorrect preparation of a drug before administration
- · Improper technique when administering a drug
- · Giving a drug that has deteriorated
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Preventing medication errors:
- · Do not allow the automatic habits of preparing medications or the use of technology to replace constant thinking, purposeful action, and repeated checking for accuracy.
- · Observe the three checks and the five rights of medication administration
- o Always read the label three times and check the medication order before administering
- · Accurate and timely documentation
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More preventing errors:
- · Medication reconciliation performed at points of transition in patient care
- · When in doubt, always check an order with the prescriber, a pharmacist or the literature
- · Do not try to decipher illegibly written orders
- · Avoid dosage and product abbreviations
- · Never assume route of administration
- · Be alert; never too busy to stop and check
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When an error is made:
- · Need to immediately acknowledge the error
- · Monitor patient condition and observe for adverse effects
- · Follow established protocols for reporting
- o Notify nurse manager and physician
- o Complete form used for reporting errors
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Controlled substance:
- · Controlled substances (narcotics) are kept in a a double locked draw or container
- · Federal law requires that a record must be kept of each narcotic administered
- · Narcotics are counted when each drug is removed from the drawer and at the end of each shift
- · Incorrect narcotic counts must be reported immediately
- · Secure Identification Code = Nurses Signature
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Discarded Narcotics:
- · Unused narcotics are either returned to the pharmacy or discarded
- · Discarded narcotics must be witnessed by another nurse
- · Both nurses sign the narcotic sheet
- · Consult the policy of the facility for specific guidelines
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Medication and home:
- · Nurses need to educate patients and families about medications
- o General information about medications
- o How to take medications
- o Special instructions
- · Every patient should know and understand what they are taking prior to discharge
- · Provide oral and written information about medications
- · Teaching to Promote Health at Home - Medications (Taylor p. 816)
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