9/22/21 1 2 MEDICATION LEGISLATION AND STANDARDS Federal regulations ­Pure Food and Drug Act ­Food and Drug Administration (FDA) ­MedWatch program State and local regulation of medication Health care institutions and medication laws Medication regulations and nursing practice (Nurse Practice Acts) 3 CASE STUDY Esther Simmons is an 85-year-old African-American woman who lives in her home. Esther is on a skilled care floor in a hospital following hip replacement surgery. Her strength and mobility are improving, and she is planning to return home with home care nursing within the week. Emilio Fernandez is a 31-year-old nursing student who is assigned to care for Esther today. While reviewing the medical record, Emilio finds that Esther has several chronic illnesses: diabetes, heart disease, hypertension, and arthritis. 4 PHARMACOLOGICAL CONCEPTS Medication names ­Chemical— Provides the exact description of meds composition. ­Generic— The manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia (acetemenophin) ­ ­Trade— Also known as brand or proprietary name. This is the name under which a manufacturer markets the med. (Tylenol) 5 PHARMACOLOGICAL CONCEPTS Classification ­Effect of medication on body system ­Symptoms the medication relieves ­Medication’s desired effect Medication forms ­Solid, liquid, other oral forms; topical, parenteral; forms for instillation into body cavities ­ 6 1 into body cavities ­ 6 QUICK QUIZ 1. You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with: A. absorption. B. biotransformation. C. distribution. D. excretion. ***** 7 CASE STUDY Esther needs to take many medications on a routine basis. Several of Esther’s medications have changed, and several have been added since she was admitted. Based on this assessment, Emilio determines that Esther needs to learn how to administer her medications safely at home. Emilio learns that patients tend to manage their medications at home better when they understand their medication regimen and when they are able to afford their medications. 8 PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTIONS Absorption ­Passage of medication molecules into the blood from the site of administration ­Factors that influence absorption ­ Route of administration ­ Ability of a med to dissolve ­ blood flow to the site of admin. ­ Body surface area ­ lipid solubility 9 PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTIONS Distribution ­ Circulation ­ membrane permeability 10 9 ­ Circulation ­ membrane permeability ­ protein binding Metabolism ­Medications are metabolized into a less-potent or an inactive form. ­__Biotransformation___ occurs under the influence of enzymes that detoxify, break down, and remove active chemicals. 10 PHARMACOKINETICS AS THE BASIS OF MEDICATION ACTIONS Excretion ­Medications exit the body through the: ­ Kidney ­ Liver ­ Bowel ­ Lungs ­ Exocrine glands ­Chemical makeup of medication determines the organ of excretion. 11 TYPES OF MEDICATION ACTION Therapeutic effect: Adverse effect: Unintended, undesirable, often unpredictable ­Side effect: Predictable, unavoidable, secondary effect. ­Toxic effect: Accumulation of med in the bloodstream ­Idiosyncratic reaction: Overreaction or underreaction or different reaction (should not of happened, IDIOT lol) 12 TYPES OF MEDICATION ACTION Allergic reaction ­ Unpredictable response to a med Medication interactions ­ One medication modifies the action of another ­ Medication tolerance ­ More meds are req to achieve the same therapeutic effect. ­ Medication dependence ­ Physical 13 Medication dependence ­ Physical ­ Psychological 13 QUICK QUIZ 2. A postoperative patient is receiving morphine sulfate via patientcontrolled analgesia (PCA). The nurse assesses that the patient’s respirations are depressed. The effects of the morphine sulfate can be classified as: A. allergic. B. idiosyncratic. C. therapeutic. D. toxic.**** 14 TIMING OF MEDICATION DOSE RESPONSES Therapeutic range Peak Trough Biological half-life Plateau Time-critical medications Patient teaching 15 ROUTES OF ADMINISTRATION Oral routes ­Sublingual administration ­Buccal administration ­Enteral (swallow or gastronomy) 16 ROUTES OF ADMINISTRATION Parenteral routes ­Four major sites of injection ­ intradermal (dermis) ­ subcutaenous (subcut fat layer) ­ intramuscular (muscle) ­ intravenous (into the vein) ­Other routes ­ epidural, intrathecal, inraaosseous, intraperitoneal, intrapleural, 17 ­Other routes ­ epidural, intrathecal, inraaosseous, intraperitoneal, intrapleural, intraarterial. (joint) ­Routes usually limited to physicians ­ Intracardiac and intraarticular. 17 ROUTES OF ADMINISTRATION Topical administration ­Skin/transdermal (through the dermis) ­Mucous membranes (nasal spray) Inhalation route ­Metered-dose inhalers or dry-powder inhalers (inhaler) Intraocular route ­Eye drops- use medical asepsis, don’t drop right onto cornea, place in conjunctival sac and close the eye gently. 18 SYSTEMS OF MEDICATION MEASUREMENT Metric system ­Most logically organized ­ Meter, liter, gram ­ Never use a trailing zero Household system ­Most familiar to individuals ­Disadvantage: inaccuracy Solutions ­When a solid is dissolved in fluid, concentration is expressed as ­Units of mass per units of volume (g/L, mg/mL) ­Percentage (10% solution) ­Proportions (1/1000) 19 NURSING KNOWLEDGE BASE Medical errors ­More people die from medical errors than from chronic lower respiratory diseases, accidents, stroke, Alzheimer’s disease, and diabetes mellitus Nurses play an important role in patient safety ­ Think critically to ensure safe med administration. 20 CLINICAL CALCULATIONS Conversions within one system Conversions between systems 20 Conversions within one system Conversions between systems Dose calculations ­ The ratio and proportion method ­ The formula method ­ Dimensional analysis**** Pediatric doses ­Calculations require special caution, weight based IV flow rates. 21 HEALTH CARE PROVIDER’S ROLE Prescribers ­Physicians, nurse practitioners, physician’s assistants Orders ­Written (hand or electric) ­verbal ­telephone Abbreviations ­Can cause errors; use caution ­Know prohibited and error-prone abbreviations 22 TYPES OF ORDERS IN ACUTE CARE AGENCIES Standing orders or routine medication orders prn orders Single (one-time) orders (may not be a stat or now but just given once) STAT orders (order that should be given rn) Now orders (generous time frame/you got like60-90min) Prescriptions (send with them when discharged to get filled) 23 EXAMPLE OF A MEDICATION PRESCRIPTION 24 MEDICATION ADMINISTRATION Pharmacist’s role ­Prepares and distributes medication Nurse’s role ­ determines meds orders are correct ­ Assess patients ability to self administer ­ determines med timing ­Admin med correctly ­ closely monitors effect ­ provides patient teaching 25 ­ closely monitors effect ­ provides patient teaching ­ does not delegate med admin to AP ­ 25 MEDICATION ADMINISTRATION Distribution systems ­Unit dose systems ­Automatic medication dispensing system [AMDS]) 26 MEDICATION ERRORS Medication error ­Any preventable event that may cause inappropriate medication use or jeopardize patient safety When an error occurs ­First _assess_the patient’s condition, then notify the health care provider ­When patient is stable, report the incident ­Prepare and file an ­Report near misses and incidents that cause no harm During transitions in care, reconcile medications 27 CASE STUDY Emilio anticipates that Esther will have difficulty getting her medicine from the pharmacy because of her hip replacement. Emilio asks Esther about her relationships with family and friends and assesses her spiritual and religious preferences. He asks Esther to identify family and friends who can help her when she goes home. After discovering that Esther is active in her church, Emilio gets permission from Esther to contact the church’s minister. Emilio asks the minister to identify church members who are able to help Esther get to the pharmacy or to go to the pharmacy for her. 28 QUICK QUIZ 3. If a nurse experiences a problem reading a physician’s medication order, the most appropriate action will be to: A. call the physician to verify order. *** B. call the pharmacist to verify order. C. consult with other nursing staff to verify. D. withhold the medication until physician makes rounds. 29 D. withhold the medication until physician makes rounds. 29 CRITICAL THINKING Knowledge Experience ­ psychomotor skills Attitudes ­ be disciplined ­ be responsible and accountable Standards ­ ensure safe nursing practice. 30 CRITICAL THINKING*** Seven rights ­Right patient ­Right drug/ meds ­Right dose ­Right route ­Right time ­Right documentation ­Right indication Maintaining patients’ rights 31 QUICK QUIZ 4. Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it. B. Medication after administering it. *** C. Rationale for administering it. D. Prescriber rationale for prescribing it. 32 NURSING PROCESS: ASSESSMENT Through the patient’s eyes ­Consider patients’ preferences and values ­Assess patient experiences History ­ Allergies ­ medications 33 ­ Allergies ­ medications ­ diet history ­ patients perceptual or coordination problems. 33 NURSING PROCESS: ASSESSMENT Patient’s current condition Patient’s attitude about medication use Factors affecting adherence to medication therapy Patient’s learning needs 34 CASE STUDY Emilio finds out that Esther will be going home in a few days. Before she can leave, she needs to learn how to self-administer her medications safely. Older adult patients often have difficulty with medication adherence because they have difficulty affording medications. They often take medications out of their normal containers, have difficulty opening packages, and often have problems related to health literacy. 35 NURSING DIAGNOSIS Nursing diagnoses that may apply during medication administration ­Impaired Health Maintenance ­Lack of Knowledge (Medication) ­Nonadherence (Medication Regimen) ­Adverse Medication Interaction ­Complex Medication Regimen (Polypharmacy) 36 PLANNING Organize care activities to ensure the safe administration of medications Goals and outcomes ­Setting goals and related outcomes contributes to patient safety and allows for effective use of time during medication administration. Setting priorities ­Provide the most important information about the medications first. Teamwork and collaboration 37 CASE STUDY Emilio plans a teaching session with Esther. His goal is that Esther will 37 CASE STUDY Emilio plans a teaching session with Esther. His goal is that Esther will be able to self-administer her medications safely and correctly. Strategies: ­ Emilio plans to sit with Ester as at a table in a room that is well lit and has limited distractions (TV off) ­ He will include Esther’s caregivers in educational settings. ­ He will ask Esther’s caregiver to bring all her meds from home to the hospital. They will compare the meds. Esther has at home meds with the ones she is going to take home to determine which meds Esther understands. 38 IMPLEMENTATION Health promotion ­Patient and family caregiver teaching Acute care ­Receiving, transcribing, and communicating medication orders. ­Accurate dose calculation and measurement Avoidance of distractions ­Correct administration ­Recording medication administration Special considerations ­Infants and children ­Older adults ­Polypharmacy ­ 39 EFFECTS OF AGING ON MEDICATION METABOLISM 40 CASE STUDY Emilio plans to assess Esther’s health literacy by determining her ability to understand what she reads and to do simple medication calculations. If she has poor health literacy, he will ensure that information is presented at a level that Esther can understand and will arrange for help from family, friends, and/or home care nurses. Emilio will review with Esther information about the medications: desired effect, dose, frequency, and adverse effects. He will show her how to use a medication organizer but will encourage her to leave medications in their original containers. 41 42 medications in their original containers. 41 CASE STUDY Emilio will provide patient teaching materials that include helpful pictures to enhance Esther’s understanding of prescribed medications. He will ensure that print and pictures on the teaching sheets are large enough for Esther to see. 42 EVALUATION Through the patient’s eyes ­Partner with your patients. ­Ensure patients understand and can safely administer their medications. Patient outcomes ­Use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual findings. 43 CASE STUDY Emilio decides on these strategies to help Esther: ­Ask Esther questions about her medications, such as, “ Why are you taking these meds?” and “ When do you take you meds?” ­Ask Esther to write out a medication schedule that includes how much of each medication she should take and when to take it. ­Have Esther verbalize symptoms related to the possible adverse effects of meds she is takings and identify what to report to her hcp. ­Have Esther set up her own medications for one day, and evaluate her accuracy. 44 45 ORAL ADMINISTRATION Easiest and most desirable route, least expensive, convinient Food sometimes affects absorption. Protect patients from aspiration. Follow special precautions when administering medications to patients with enteral or small-bore feeding tubes ­ Follow tubing connection standards ­ Verify tube is compatible with med absorption ­ use liquid meds when possible ­ flush between meds ­ ­ flush between meds ­ ­Tablets, capsules, liquids, suspensions, elixirs, lozenges. 45 TOPICAL MEDICATION APPLICATIONS Skin applications ­Ask patients if they take any topical medications. ­When applying a transdermal patch, ask the patient whether he or she has an existing one on. ­ ­Wear disposable clean gloves when removing and applying transdermal patches. ­If the dressing or patch is difficult to see (e.g., clear), apply a noticeable label to the patch. ­Document patch or medication location on the MAR ­Document patch or medication removal on the MAR 46 NASAL INSTILLATION Methods ­ Spray (nasacort, afrin) ­ drops ­ tampons (rod of cotton you put up the nose) Decongestant spray or drops most common ­Caution patients to avoid the rebound effect ­Serious systemic effects also develop if excess decongestant solution is swallowed, especially in children 47 EYE INSTILLATION Instillation ­Avoid the cornea ­Avoid touching eye or eyelid with droppers or tubes (medical asepsis) ­Use only on the affected eye. ­Never share eye medication!!! Intraocular instillation ­Disk resembles a contact lens. ­Teach patients how to insert and remove the disk. ­Teach about adverse effects. 48 ­Teach about adverse effects. 48 EAR INSTILLATION Eardrops ­Instill eardrops at room temp ­Use sterile solutions ­Check with the health care provider for eardrum rupture if patient has ear drainage. ­Never occlude the ear canal Irrigation ­Performed to remove cerumen that cannot be removed with wax softeners ­Performed only in cases of hearing deficit, ear discomfort, or to visualize the tympanic membrane 49 VAGINAL INSTILLATION Vaginal medications ­Inserted with a gloved hand ­ suppositories ­Administered with an applicator inserter ­Foam ­Jellies ­Creams 50 RECTAL INSTILLATION Rectal suppositories ­ Thinner and more bullet-shaped than vaginal suppositories ­Rounded end prevents anal trauma during insertion ­Contain medications that exert local effects ­A small cleansing enema may be required before inserting a suppository 51 ADMINISTERING MEDICATIONS BY INHALATION Pressurized metered-dose inhalers (pMDIs) ­ Required hand strength and hand breath coordination ­ may be used with spacer Breath-actuated metered-dose inhalers (BAIs) ­ release depends on strength of patients breath on inspiration Dry powder inhalers (DPIs) ­ activated by patients breath 52 Dry powder inhalers (DPIs) ­ activated by patients breath ­ deliver more medication to the lungs 52 ADMINISTERING MEDICATIONS BY IRRIGATIONS Irrigations most commonly use sterile water, saline, or antiseptic solutions on the eye, ear, throat, vagina, or urinary tract. Use __aseptic_ technique if there is a break in the skin or mucosa. Use _clean___ technique when the cavity to be irrigated is not _sterile_, as in the case of the ear canal or vagina. Irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue. 53 PARENTERAL ADMINISTRATION OF MEDICATIONS Equipment ­Syringes ­Luer-Lok (it has a thread to it; spiral) ­Non–Luer-Lok ­Needles ­Hub ­Shaft ­Bevel (angle part; hole) ­Disposable injection units ­ ­ 54 PARENTERAL ADMINISTRATION OF MEDICATIONS 55 PARENTERAL ADMINISTRATION OF MEDICATIONS Preparing an injection from an ampule ­ snap off ampule neck ­Aspirate medication into syringe using ­Replace _filter needle with an appropriate size needle or needless device ­Administer injection 56 PARENTERAL ADMINISTRATION OF MEDICATIONS Preparing an injection from a vial ­If dry, use solvent or diluent as needed 57 56 Preparing an injection from a vial ­If dry, use solvent or diluent as needed ­Inject air into vial ­Label multidose vials after mixing ­Refrigerate remaining doses if needed 57 PARENTERAL ADMINISTRATION OF MEDICATIONS Mixing medications ­Mixing medications from a vial and an ampule ­Prepare medication from the vial first. ­Use the same syringe and filter needle to withdraw medication from the ampule. ­Mixing medications from two vials ­Do not contaminate one medication with another. ­Ensure that the final dose is accurate. ­Maintain aseptic technique. ­ 58 PARENTERAL ADMINISTRATION OF MEDICATIONS 59 PARENTERAL ADMINISTRATION OF MEDICATIONS Insulin preparation ­Insulin is the hormone used to treat diabetes. ­It is administered by injection because the GI tract breaks down and destroys an oral form of insulin. ­Use the correct syringe: ­100-Unit insulin syringe or an insulin pen to prepare U-100 insulin ­Insulin is classified by rate of action: ­ rapid, short, intermediate, and long acting ­Know the onset, peak, and duration for each of your patients’ ordered insulin doses. 60 PARENTERAL ADMINISTRATION OF MEDICATIONS Mixing insulins ­Patients whose blood glucose levels are well controlled on a mixedinsulin dose need to maintain their individual routine when preparing and administering their insulin. ­Do not mix insulin with any other medications or diluents unless approved by the health care provider. ­Never mix glargine or insulin detemir with other types of insulin. 61 approved by the health care provider. ­Never mix glargine or insulin detemir with other types of insulin. ­Inject rapid-acting insulins mixed with NPH insulin within 15 minutes before a meal. ­Verify insulin doses with another nurse while you are preparing the injection. 61 PARENTERAL ADMINISTRATION OF MEDICATIONS Administering Injections ­Each injection route differs based on the types of tissues the medication enters. ­Before injecting, know: ­The volume of medication to admin. ­The characteristics and viscosity of the meds. ­The location of antamical structures =underlying the Injection site ­Minimize patient discomfort 62 PARENTERAL ADMINISTRATION OF MEDICATIONS Subcutaneous injections ­Medications placed into loose connective tissue under dermis ­ ­ Exercise and hot or cold compress influence rate of absorption ­Administration of low-molecular-weight heparin requires special considerations. 63 PARENTERAL ADMINISTRATION OF MEDICATIONS 64 PARENTERAL ADMINISTRATION OF MEDICATIONS New technologies for administration of subcutaneous injections ­Injection pens ­Needleless jet injection systems ­Subcutaneous injection devices 65 PARENTERAL ADMINISTRATION OF MEDICATIONS Intramuscular Injections ­Faster absorption than subcutaneous route ­Angle of administration: 90 degrees ­Needle length and site tailored to patient ­Amounts: ­Adults: 2-5 ml (4-5 ml unlikely to be absorbed properly) ­Children, older adults, thin patients: up to 2 ml 66 67 ­Adults: 2-5 ml (4-5 ml unlikely to be absorbed properly) ­Children, older adults, thin patients: up to 2 ml ­Small children and older infants: up to 1 ml ­Smaller infants: up to 0.5ml ­Z-Track method 66 PARENTERAL ADMINISTRATION OF MEDICATIONS 67 PARENTERAL ADMINISTRATION OF MEDICATIONS Ventrogluteal site ­Gluteus medius ­Preferred and safest site for all adults, children, and infants ­V method ­ 68 PARENTERAL ADMINISTRATION OF MEDICATIONS Vastus lateralis ­Used for adults and children ­Use middle third of muscle for injection ­Often used for infants, toddlers, and children recieving biologicals ­ 69 PARENTERAL ADMINISTRATION OF MEDICATIONS Deltoid ­Not well developed in many adults ­Proximity to nerves and artery create potential for injury. ­Volume: less than 2 mL ­Site is 3 finger widths below the acromian process. 70 PARENTERAL ADMINISTRATION OF MEDICATIONS Intradermal injections ­Used for skin testing (TB, ALERGIES) ­Blood supply in the dermis in the dermis is reduced and med absorption occurs quickly. ­Skin testing requires the nurse to be able to clearly see the injection site for changes ­Use a tuberculin or small hypodermic syringe for skin testing ­Angle of insertion is 5-15 degrees with bevel up ­A small bleb will form 71 72 ­A small bleb will form 71 PARENTERAL ADMINISTRATION OF MEDICATIONS Safety in administering medications by injection ­Needleless devices ­Needlestick Safety and Prevention Act ­Safety syringes ­Dispose of needles and other instruments considered sharps into clearly marked, appropriate containers 72 PARENTERAL ADMINISTRATION OF MEDICATIONS Intravenous administration ­Nurses administer medications intravenously by the following methods: 1.___infusion of large volumes of IV fluid_containers that contain medications mixed, labeled, and dispensed by pharmacy 2.__injection of a bolus or small volume _of medication through an existing IV infusion line or intermittent venous access (heparin or saline lock) 3._”Piggyback” __infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line 73 PARENTERAL ADMINISTRATION OF MEDICATIONS Large-volume infusions ­Safest and easiest method of IV administration. ­Pharmacies prepare medications in large volumes (500 or 1000ml) of compatible IV fluids ­If infused too rapidly, patient is at risk for overdose and fluid overload. ­Nurses mix medications into IV fluids only in _emergency situations_and never prepare high-alert medications. ­Monitor patients closely for adverse reactions. 74 PARENTERAL ADMINISTRATION OF MEDICATIONS Intravenous bolus ­Introduces a concentrated dose of medication directly into the systemic circulation ­Advantageous when the amount of fluid that a patient can take is restricted. ­The most dangerous method for medication administration because there is no time to correct answers 75 ­The most dangerous method for medication administration because there is no time to correct answers ­Confirm placement of IV line in a healthy site. ­Determine the rate of administration by the amount of medication that can be given each minute. 75 PARENTERAL ADMINISTRATION OF MEDICATIONS Volume-controlled infusions ­Uses small amounts (50-100mL) of compatible fluid ­Three types of containers: volume-control admin sets, piggyback set, and syringe pumps. ­ ­Advantages of volume-controlled infusion: ­Reduces the risk of rapid dose infusion by IV push ­Allows for administration of medications that are stable for a limited time in a solution ­ ­Allows control of IV fluid intake 76 PARENTERAL ADMINISTRATION OF MEDICATIONS ­A small (25 to 250 mL) IV bag or bottle connected to a short tubing line that connects to the upper Y-port of a primary infusion line or to an intermittent venous access 77 PARENTERAL ADMINISTRATION OF MEDICATIONS 78 PARENTERAL ADMINISTRATION OF MEDICATIONS Volume-control administration ­Small (150-mL) containers that attach just below the primary infusion bag or bottle Syringe pump ­Battery operated ­Allows medications to be given in very small amounts of fluid (5-60 mL) within controlled infusion time using standard syringe 79 PARENTERAL ADMINISTRATION OF MEDICATIONS Intermittent venous access (saline lock) ­Advantages: ­Cost savings resulting from the omission of continuous IV therapy 79 ­Advantages: ­Cost savings resulting from the omission of continuous IV therapy ­Effectiveness of nurse’s time enhanced by eliminating constant monitoring of flow rates ­Increased mobility, safety, and comfort for the patient ­Before administration: ­ Assess the patency and placement of the IV site ­After administration: ­ Access must be flushed with a solution to keep it patent 80 PARENTERAL ADMINISTRATION OF MEDICATIONS Administration of IV therapy in the home ­Usually patients have a central venous catheter. ­Home care nurses assist with monitoring. ­Carefully assess patients and their families to determine their ability to manage this therapy at home. ­Begin instruction on IV care management while the patient is still in the hospital. Teach family and patient: ­To recognize signs of infection and complications ­When to notify the home care nurse or health care provider ­How to maintain IV administration equipment 81 SAFETY GUIDELINES FOR NURSING SKILLS Be vigilant during medication administration. Verify that medications Use at least _2 indentifiers__before administering medications, and check against the med admin record (MAR) Before administering medication, check for accuracy 3 TIMES Clarify unclear medication orders and ask for help if needed. 82 SAFETY GUIDELINES FOR NURSING SKILLS Use the technology available in your agency when preparing and giving medications. Use strict _aseptic__technique during parenteral medication preparation and administration. ___Educate patients__about each medication. Most of the time you cannot delegate medication administration. Follow safety guidelines to prevent needlestick injuries. 83 REFERENCES Assessment Technologies Inc (2019). Fundamentals for Nursing (10th 83 REFERENCES Assessment Technologies Inc (2019). Fundamentals for Nursing (10th ed). Potter, P.A. & Perry, A.G. (2021). Fundamental concepts and skills of nursing (10th ed.). St. Louis: Mosby Elsevier.
