Pharm 2

• Standing: carried out as specified until cancelled by another order
• PRN: as needed, when requested or required, often for symptoms
• Stat: single, one time directive order, carried out immediately (usually an emergency)

• Patient Name
• Date and Time order was written
• Name of Drug
• Dosage of Drug (can be metric, apothecary, or household)
• Route of Administration
• Frequency of Administration
• Signature of person writing order

• MAR: Medication Administration Record (includes orders and administrations)
• CMAR: Computerized Med Admin Record (more popular)
• Check correct transcription and question if necessary
• Document omitted drugs, both intentional and inadvertently omitted
• --Intentional: (a) fasting before a diagnostic test, (b) problem no longer exists, (c) suspected allergy
• Document refused drugs: report problem and reason for refusal, patients have a right to refuse, so don’t push

• Stock Supply: large quantities on unit, immediately available to nurses
• ADC: Automated Dispensing Cabinets (computerized)
• Med Cart: one drawer per patient name on the unit, push cart around to patient rooms
• Barcodes: on patient, nurse ID, medication container; computer also documents administration

• Metric: meter (linear), liter (volume), gram (weight)
• Apothecary: grain (weight); minim, dram, ounce, pint, quart (volume); roman numerals used
• Household: teaspoon, tablespoon, teacup, glass

Assure the right medication is given to the right patient in the right dose by the right route at the right time. Follow with the right documentation. Also added is knowing the right reason for medication. (and check expiration)

• When the nurse reaches for the container or unit dose package
• After retrieval from drawer and compare with MAR, or compare with MAR immediately before pouring from a multi-dose container
• When replacing drug to drawer/shelf or giving unit dose medication to patient

• “preventable inappropriate use of medications”
• Occur when ordered, transcribed, dispensed, administered, monitored
• Extremely important are the 5 rights and 3 checks
• Patient Safety comes first:
• --Check the patient’s condition- note any adverse effects
• --Notify nurse manager/physician so a course of action can be determined, if necessary
• --Describe error in patient record and any remedial steps taken
• --Complete incident form according to agency policy

• Inappropriate prescribing
• Extra, omitted, wrong doses
• Administration of medication that wasn't ordered
• Incorrect route or rate of admin
• Failure to give medication within time interval
• Incorrect preparation of drug before admin
• Improper technique of admin
• Giving a deteriorated drug

• Locked drawer, only ordered by a physician, record must be kept, check narcotics regularly, usually during shift change (or computer records it), witness and record when discarding is needed
• --Name of patient
• --Amount of narcotic used
• --Hour the narcotic was given
• --Name of physician who prescribed the narcotic
• --Name of the nurse who administered the narcotic

• Stomach/Small Intest: solid, liquid powder
• Special Techniques: damage to teetch, bad taste, children, older adults
• Enteral Feeding Tube: liquid med or crushable into liquid, room temp only, elevate head to prevent reflux
• Sublingual/Buccal meds: oral care, drink water prior, dont swallow

• Outside of intestines/alimentary canal (injections)
• Equipment: needles, syringes, needless
• Intradermal, Subcutaneous, Intramuscular, Intravenous

• Into dermis, below epidermis, longest absorption time
• Inner forearm, or upper back under scapula
• (3-4 fingers below antecubital space, one hand-width above wrist)
• Used for tuberculin test, allergy tests, local anesthesia

• Adipose tissue just below dermis/epidermis
• slow/sustained rate of absorption
• Sites: (faster) abdomen, arms, thighs, upper ventral or dorsogluteal areas (slower)

• Faster absorption, depot at site allows for longer duration of effect and sustained release
• Site is chosen carefully, according to criteria
• Z-Track Technique: pulling skin taut either one inch to side or spreading skin between 2 fingers, slowing inject medication and steadily withdraw needle, releasing skin (reduces patient discomfort)

• Directly into bloodstream, immediate/irreversible effect, most dangerous, sterile technique
• PCA: patient controlled analgesia for pain management
• Via Intravenous Solution: added to patient’s infusion solution, requires sterile technique, slow admin over long time period, check for adverse reactions every hour
• Via IV Bolus or Push: single injection of concentrated solution directly into IV line, delivered very slowly over one minute, according to pharmacist or drug reference
• Via Intermittent IV Infusion: drug mixed with small amount of IV solution (50-100mL), admin’d over short period at prescribed intervals (ex. q4hr), gravity infusion is drops per minute, infusion pump/smart pump can be used to program infusion rate, needleless (blunt cannula/recessed connection port)
• -- Piggyback Delivery System: intermittent or additive solution hung higher than primary solution, backcheck valve stops primary when additive is connected (tandem is similar)
• --Volume Control Admin Set: intermittent solution med is diluted in small amount and admin’d into IV line, used when volume of fluid infused is a concern
• --Mini-Infusion Pump: (syringe pump) intermittent battery operated, medication mixed in syringe is connected to primary line, delivered by mechanical pressure applied to syringe plunger
• --Med/Drug Infusion Lock: (“intermittent peripheral venous access device”) needle/catheter, short tube capped with sealed injection port; allows patient freedom (only when med is needed); flush with small amount of saline or heparin

• ¼"- ½" length
• 26-27 gauge needle
• 10-15 deg
• Dose: small, <5mL
• Site: upper left forearm, upperback under scapula

• 3/8” – 1” (but usually just 5/8”)
• 25-30 gauge
• 3/8” is 90 deg
• 5/8” is 45 deg
• (angle always depends on tissue present)
• Dose: <1mL
• Sites: bilaterally upper back, upper arm, abdomen, upper thigh, upper dorsal/ventral gluteal

• length depends on site and age
• 5/8"-1 1/2" (usually 1-1 1/2")
• 25-20 gauge- aqueous solution
• 25-18 gauge- oil-based solution
• 72-90 deg
• Dose: generally 1-4mL (Deltoid/Child 1-2mL)
• Sites: Dependent on age, medication type, medication volume
• --Ventrogluteal: gluteus minimus and medius in hip area; used for adults, depot formulas, solutions that are irritating/viscous/oily
• --Vastus Lateralis: quadriceps femoris along anterolateral thigh; used for biological for infants, children
• --Deltoid Muscle: lateral upperarm, <1mL and only adults

• Ampule: (glass flask, single dose) discard unused portion, use filter need/discard it/change to appropriate needle, don’t touch needle to rim
• Vial: (glass bottle with self-sealing rubber stopper) multidose vials use/discard within 24hr (mark date and time of first use), alcohol wipe after each use, inject same amount of air as desired dose
• Prefilled Cartridge/Syringe: (single dose) clear excess air, eject excess med so only exact dost is given (tubex, carpuject)

• (ensure compatibility*)
• Inject air into both, draw from multiuse vial before single use
• Draw from a vial before an ampule
• Discard if cloudy once mixed
• Insulin: (clear)short acting/ intermediate-acting/ long-acting(cloudy), onset time/peak/duration of effects, scale is U100 (100 units insulin per 1mL) or U25 (infant/child), never shake to mix

• (“inuction”)absorption increased by cleaning site, ointment/liniment that will mix with fat in sebaceous gland lining, applying local heat
• --Powder: promotes drying, prevents friction
• --Ointment: prolonged contact, softens skin
• --Cream/Oil: lubricate/soften skin, prevent drying
• --Lotion: protect/soothe skin
• --Transdermal skin disk or patch: daily or longer use, slow onset

• into lower conjunctival sac
• Instilling Eyedrops: local effects
• Ointment: ½” along exposed lower conj. Sac, close eye, most eye around but don’t rub eye; for local infection and irritation
• Irrigation: to remove secretions/foreign bodies, cleanse/soothe eye; chemical flush- for 15 min
• Eye Medicated Disk: resembles contact lens, gradual release, covered by lower lid

• Ear Drops
• Irrigation: for cleaning or applying heat; room temp, saline/antiseptic solution, irrigation syringe

• for local allergies, sinus infection, nasal congestion (or vasopressin has systemic effects)
• Dropper or spray

• application with cream, foam, or tablets or just suppository
• Void before medication admin; remain in supine for 5-10 minutes

• laxative, fecal softener (takes 35-40 min)
• or systemic (antipyretic, analgesic, antiemetic)
• remain in position 5 min

• Aerolized, small particles, breathed in; fast absorption but hard to track dosage (ex. bronchodilator)
• Hand atomizer or nebulizer (mist), MDI (metered-dose inhaler); requires spacer for children or those with difficulty breathing
• Intermittent positive-pressure breathing machine (type of nebulizer)
• DPI (dry powder inhaler): breath activated

• Begins upon adminission
• Tailor to patient’s level of understanding and provide written instructions
• Teach technique to patient and family; patient demonstrates before discharge
• Instruct to take as prescribed (length, dose, number of doses)
• Nurse promotes public/individual education, prevent drug abuse

• Adverse effects on fetus; consult physician before any drug use
• Teratogenic: causes developmental effects on embryo or fetus
• Drugs cross through placenta and breastmilk

• Child is smaller size, weight, body water so dose is lower
• Infants have immature organs and blood brain barriers
• Doses are according to BSA (height and weight relationship)
• Use West Nomogram to calculate BSA
• Note of medication is per dose or per 24hr period

• Decreased mobility, muscle mass, acid production, blood flow (affects absorption)
• Increase in side effects: liver function, kidney function are impaired
• More susceptible to drug interactions
• Patient education is key to success in adherence to medication programs

• Nursing history/Medication history Use familiar terms, not medical jargon Health Status and current/past illness
• Laboratory test results
• Drug allergiesAssessment continues during and after administration

• Medication Administration Related Diagnoses
• Ex. “Anxiety related to daily self-injection of insulin”

• Expected therapeutic effects will be demonstrated
• Expected change in symptoms
• Maintenance of therapeutic blood levels of medication
• Patient will demonstrate knowledge regarding his/her medication

• Make sure med is taken
• Offer several drugs separately
• Never leave meds to be taken later
• Record admin asap, within 30 min

• Subjective “patient statements”
• Objective (vitals)
• Adverse effects
• Patient drug levels in therapeutic range
• Patient verbalizes education