Nursing Management of
Clients with Stressors
Requiring Medication
Administration
NUR101 Fall 2008
K. Burger
Lecture # 10
PPP by:
Sharon Niggemeier RN, MS
(J. Garnar & R.Kolk)
Revised 1006,1007 KBurger
Regulatory Needs
Pharmacology Principles
The Nurse’s Role
Pharmacology
Pharmacology: is the study of chemicals/drugs and
their effects on living organisms.
• Drugs (legal and illegal) are chemicals intended
to elicit a specific effect.
• Drugs alter physiological functions in the body,
they do not create a new function in a tissue or
organ.
• Drugs also create unwanted effects in addition
to the desired effect.
Terminology
• Pharmacotherapeutics: use of drugs to treat or
prevent disease. It can be preventative, palliative, or
restorative. “Why a drug is prescribed”.
• Pharmacokinetics: (means "drug movement") the
study of the concentration of a drug during the processes
of absorption, distribution, biotransformation
(metabolism), and excretion of a drug. “What the
body does to the drug”
• Pharmacodynamics: study of the mechanism of
drug action on living tissue at the cellular level. “What
the drug does to the body”
NCLEX Time
A nurse administering medications has many responsibilities.
Among these responsibilities is a knowledge of
pharmacokinetics. Which statement is the best description of
pharmacokinetics?
• A.The passage of medication molecules into the blood from
the site of administration
• B.The degree to which medications bind to serum proteins,
which affects distribution
• C.The study of how medications enter the body, reach their
site of action, metabolize, and exit the body
• D.The method by which a medication, after absorption, is
moved within the body to tissues, organs, and specific sites of
action
Nursing Responsibilities:
Remember that drugs can help
or harm
• Nurses are liable for their actions,
omissions, and for those duties they may
delegate to others.
• They are personally responsible…legally,
morally and ethically…for every drug they
administer.
Nursing Responsibilities
• Obtaining current knowledge base of drugs
• Referring to authoritative sources in professional
literature (PDR, journals, etc.) (less than 5yrs old)
• Questioning a drug order that is unclear or that
appears to contain an error
• Refusing to administer a drug if there is a reason to
believe it will be harmful.
• Performing correct techniques and precautions
• Monitoring client response and documenting drug
effects
• Patient and family education
Nursing Process & Drug Administration
ASSESSMENT – Thorough collection of data
• Information about the medication
Action – side effects – appropriate dose
Age specific considerations – routes
• Information about the client
What other medications are they taking
Allergies or other problems w/ meds
Gag reflex – Impaired swallowing
Dietary and/or Fluid restrictions
Cultural and/or religious influences
Genetic factors
Vital signs
Lab values – renal & liver function / protein & albumin
Age
Pregnant/breast feeding
Nursing Process & Drug Administration
Assessment: Pt needs to take meds, can’t
swallow
• The result of this assessment is the
NURSING DIAGNOSIS
• PLANNING: include goals that directly
relate to the nursing diagnosis and specific
outcome criteria (goals)
Nursing Process & Drug
Administration
IMPLEMENTATION
• Using correct techniques of preparation and
administration to deliver medications safely.
• Monitoring the client for therapeutic and non-therapeutic
effects of the drug
• Client education for safe and accurate self-administration
of the drug.
EVALUATION of the nursing care provided based on the
level of achievement of the outcome criteria.
Critical Thinking
The nurse is preparing to administer prescribed
antibiotics to an adult hospitalized client suffering
from a wound infection. When the nurse offers the
oral medication to the client, he says “ I’m not
taking those. Pills make me gag and throw up.”
Write a nursing diagnosis that addresses this
problem.
Impaired swallowing R/T sensitive gag reflex
AEB client reports gagging and vomiting when
attempting to take oral medications
Critical Thinking
Write an outcome statement for your
diagnosis.
Client will receive appropriate medication
therapy without discomfort or vomiting.
Critical Thinking
What are some interventions for this problem?
Determine availability of alternate oral forms:
liquid
If not contraindicated, crush medications and
mix with applesauce for administration
Critical Thinking
How will you evaluate this process?
Is client able to take medications in liquid
or crushed form without discomfort?
Is the therapeutic effect of the medication
evident ( ie: C & S -, no S/S of infection)?
Has the client experienced any adverse
effects of the medication?
Legal Aspects of Pharmacology
Purpose and Scope of Legal Controls:
• Protect public health and safety
• Laws govern testing, production,
distribution, prescription and the
administration of drugs.
Federal Medication Laws
1906 Pure Food & Drug Act
Disclosure of dangerous ingredients
1912 Sherley Amendment
No fraudulent claims of action
1914 Harrison Narcotic Act
Established regulations for narcotics
1938 Food,Drug,CosmeticAct
Drugs must be tested and proved safe
1952 DurhamHumphrey Amendment Established list of drugs needing RX
1962 Kefauver-Harris Amendment
Drugs must be proven effective
1970 Controlled Substances Act
Strict controls on distribution
1978 Drug Regulation Reform Act
Shortened drug investigation time
Controlled Substance Act
• Designed to promote treatment and prevention of drug
dependence
• Established controls such as:
-Prescribers are registered with the DEA. A registry
number is issued to each person and is renewed
annually.
-Complete written records of all drugs prescribed
must be kept for two years. Pharmacists record each
sale in triplicate. Schedule II drug prescriptions
cannot be renewed.
-DEA (Drug Enforcement Agency) monitoring
Controlled Substance Act - continued
-Health care agencies must establish policies to comply
with Federal law.
-All units have a record of every controlled drug on the
unit and two nurses at the change of every shift count all
drugs.
-All controlled drugs are stored using a double lock
system. Keys to medication areas are under the control of
nurses on the unit.
-Discarding of controlled substances must be witnessed by
another nurse
-Written renewal orders are required every 72 hours for
narcotics and schedule II & III drugs.
Control Schedule
Drugs with a significant potential for abuse
are classified into 5 categories or schedules:
Schedule I: highest potential for abuse
Illicit drugs (Heroin, LSD, Marijuana)
Schedule II: (Morphine, Dilaudid)
Schedule III: (Vicodin, Meperidine)
Schedule IV: (Valium, Xanax)
Schedule V: lowest potential for abuse
(OTC cough suppresant w/codeine)
Drug Information Resources
• The United States Pharmacopoeia ( USP)
and the National Formulary(NF) are
highly recommended for use in agencies for
all health care professionals to use as a
resource.
• Agency pharmacists are an appropriate
resource for obtaining drug information on
the job.
• Nursing drug handbooks: contain drug
information along with nursing
considerations.
Drug Information Resources-continued
• Physician's Desk Reference (PDR)
Contains manufacturer's descriptions
(package inserts) which are written using
FDA standards, but may be slanted in favor
of the drug being described.
• Package Inserts: Required by law for
insertion with each new drug and must
include a description, indications,
precautions, dosage, and contraindications.
• Electronic databases and Internet
Medication Orders
• Two ways to obtain legal drugs:
• Prescription (Rx)- order written authorizing
patient to receive medication.Prescriptions
taken to pharmacy whereby the pharmacist
dispenses the drug.
• Over the counter (OTC)- patient treats self
and doesn’t need a prescribers order. Buys
medications where ever they are available
(Walmart, 7-11, etc.)
Prescriptions
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•
•
•
•
•
•
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Written, legible prescriber’s order includes:
Patient name
Drug name
Dose
Route
Frequency
Date
Signature
Types of Medication Orders
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•
•
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STAT order: needed immediately
Single order: given only once
PRN order: given as needed
Routine orders: given within 2 hours of
being written and carried out on schedule
• Standing order: written in advance carried
out under specific circumstances.
Drug Nomenclature
• Chemical name: Precisely describes the chemical
& molecular structure of the drug.
• Generic name: Pharmaceutical name given by the
US Adopted Names Council. This name is the same
for every drug company.
eg. ibuprofen
• Proprietary or Trade or Brand name:can be
copyrighted,popular name of the drug supplied by
the manufacturer, easy to pronounce and easy to
recognize.
eg. Advil, Motrin
Look at your drug guide sample
• What is the generic name?
• What are the various trade names ?
• What do you think about this drug's various
trade names?
Example for the drug Demerol
• Chemical name: N-methyl 4 carboxypiperidine
hydrochloride
• Generic name: Meperidine
• Trade name: Demerol
• Brand name versus generic drug:
Is the drug effect identical?????????
Drug Classifications
Drugs can be classified various ways:
• Therapeutic: categorizes drugs by the disease state
they are used to treat.
• Pharmacologic: categorizes drugs by their
mechanism of action
• Controlled Substance Schedule
• Pregnancy Schedule
Example
Drug Classifications
Therapeutic Classifications
 Anti-hypertensives
 Analgesics
Pharmacologic Classifications
 Diuretics
 Beta-blockers
 Vaso-dilators
 Non-opioids
 Opioids
 Non-steroidal anti-inflammatory agents
Look at your drug guide example
• What is the Therapeutic classification?
• What is the Pharmacologic classification?
• Is it a controlled substance?
• What is the Pregnancy category?
Standards for Drugs
• Purity: Must be physically pure in that it only
contains the ingredients stated.
(very few drugs are available in a truly pure state –
THINK…what impact might this have on drug
administration?)
• Potency: Strength of the drug, measured by
standardization of weight of ingredients.
• Bioavailability: The degree to which a drug can
reach its site of action in the body.
Standards for Drugs
• Efficacy: The effectiveness of the drug in
achieving the desired biological change.
• Safety: The frequency and severity of
adverse drug reactions (ADR) determines
safety. No chemical is free of adverse
effects.
• Investigational drugs: chemicals tested
which may have potential as a new drug.
Drug Approval Process
• Pre-clinical testing on cells an animals
• Clinical testing in (4) phases
I – small # of healthy people
II – small # of people with the disease
III – large # of people with the disease
(marketing can occur after phase III)
(new expedited process allows after phase II)
IV – post marketing; voluntary
Types of Drug Preparations
• Drugs are prepared in several drug forms
depending on the route of administration or
the use that will be made of the drug.
• A variety of drug forms provide some
flexibility in the administration of drugs.
Examples: capsules, elixir, tablets, gel caps,
powders, solutions, ointments, sprays,etc.
Essential Elements of Drug
Knowledge for Nurses
• drug name(s): Locate in drug reference books,
call pharmacist to clarify when a multitude of
names for drugs causes confusion.
• drug classification: Note the classification it
provides a general view of drug as an indicator
of specific drug traits. i.e. “Antipsychotics”
• indications: why is this drug given? pain relief?
tachycardia? combat infection?
Knowledge Guidelines
• drug action: what is the drug supposed to do?
• usual dose: range will vary with age, weight,
gender and method of administration.
• route of administration: what is the preferred
route
• desired effects: what is the therapeutic effect
• side effects: predictable symptoms that occur as a
consequence of overall drug effects in the body.
Can be mild (nausea, rash) or severe/life
threatening (liver toxicity, blood dyscrasias)
Knowledge Guidelines
untoward effects: dose related symptoms occur as
dose is too high = Adverse Drug Event (ADE); or
idiosyncratic symptoms – opposite of therapeutic
effect.
• interactions with other drugs: do they potentiate
drug action (additive effect) or inhibit drug action
(antagonistic effect) or otherwise incompatible
• interactions with food: may delay absorption, may
combine with active ingredient and inactivate it.
• precautions: when does a special condition affect the
decision to use the drug?
•
Knowledge Guidelines
• contraindications: what conditions are
adversely affected by this drug?
• nursing implications:. List assessments to
be made and guidelines to be taken
• pregnancy safety: pregnancy risk
categories have been established to identify
the risk to the fetus (teratogenic effect). The
categories range from A(no risk), B, C, D,
or X (should not be used ever).
Knowledge Guidelines
patient/family education: teach patient necessary
information related to medication administration
• Be sure to answer questions and emphasize
important points!
• Some health care facilities have computer printout
on drugs that can be given to patients before
discharge.
•
• MOST ESSENTIAL:Why does this patient
need this drug?
Use your drug guide sample
to evaluate this Case Study
Your 72 y.o. client, who was admitted for dizziness
leading to a fall, has been diagnosed with
hypertension. The MD has added Lasix 40 mg
p.o. b.i.d. as well as Calan SR (antihypertensive) 120
mg p.o. daily to the client’s original medication
regimen of Digoxin 0.125 mg p.o. daily.
•What therapeutic effect is the MD expecting from the Lasix?
•What, if any, precautions should the nurse be aware of regarding
administration of Lasix to this client?
•Is this an appropriate dosage?
•What are the important nursing implications – assessment,
implementation, client teaching for administration of this drug?
Rights of Drug Administration
The (5)? Rights offer guidelines for safe drug
administration:
• Right patient
• Right medication
• Right dose
• Right route
• Right time
• Right documentation
• Right REASON
• Right of client to refuse
Standard Abbreviations
• CHECK JCAHO Official Do Not Use List
@ www.jcaho.org
• Review SCCC NUR101 Lab Worksheet
• CHECK ISMP List of Error-Prone
Abbreviations, Symbols and Dose Designations
@ www.ismp.org
Incorporating Lab Values
• Medications may be prescribed based on lab
results
• Medications may alter body functioning and
lab values may denote this
• Nursing responsibility includes
incorporating lab data with medication
administration
Some beginning
Normal Lab Values to KNOW
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Fasting Blood Glucose
Potassium (K)
Albumin
WBC
BUN
Creatinine
60-110
3.5-5.0
3.5 – 5
5000 – 10,000
10-20
0.5 – 1.2
The Case Study - continued
• Prior to administering the Lasix, the nurse
checks the lab values of the client which are:
K 3.7 / Albumin 3.0 / BUN 28 / Creatinine 0.4
What is the NEXT action the nurse should take?
Why?
Drug Calculations
• Unit dose system, less need for calculations,
still may need to calculate the number of
tablets.
• Infusions ( such as IV) calculate drops per
minute
• Conversions within the metric system
• Rarely need to calculate from apothecary
system.
• Drug calculations will be covered in
NR20Lab
Drug Supply & Storage
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Obtained from pharmacy dept.
Individual Pt. Supply UNIT DOSE
Stock supply – tylenol, ASA
Dispensing systems – medication carts,
computerized systems, ID bracelet scanning
Drug Abuse by Licensed
Professional
• Need to report suspect of abuse
Gatekeeper role of a professional nurse
• Potential loss of nursing license
• Assistance for licensed professional through
PAP (Professional Assistance Program)
NYS Education Department
Bring your LASIX handout
with you
To our next lecture on
Medication Administration