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What is the nurse's role in Rx administration
- Nurses are legally responsible for medications they administer, including knowledge of drug actions and side effects and the questioning of orders they believe are incorrect.
- Education…knowledge deficit
- Assess.. affordable, accessible, ability
- Monitor and Document
- You are the last line of defense
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More Pt rights of Rx admin
- Be informed about a medication
- Right to refuse…regardless of consequences. "Pt refused followed by education.
- Medication Reconciliation..review of medication history
- Consented prior to receiving investigational drugs
- Receive drugs safely and not unnecessarily
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Pharmacy's role
- Prep. and distribution
- Asses and evaluate Rx therapy needs
- Provide education about Rx ae to the pt.
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LIP's role
- Assess and prescribe the medication
- Computer..most accurate
- Written
- Telephone
- Read BackVerbal..ONLY in Emergent Situations
- Repeat Back
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7 Essential Elements of Rx order
- Patient Name
- Date the drug was ordered
- Name of the Drug
- Dosage (time, frequency, urgency, amount, number of doses)
- Route of administration (IV, IM, PO, etc.)
- Time and frequency drug should be given
- Signature of MD or LIP
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Standard Written
Thesea re carried out as written or until the prescriber alters or d/c an order.
ie give lasix 20mg iv BID for 5 days.
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Automatic Stop Dates
These medication orders will need renewed after a specific period of time. Pharmacy will notify the prescriber.
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STAT vs. NOW
- STAT…emergent…high priority…obtain and administer
- NOW…slightly lower priority…complete within an hour.
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Single Drug Order
One time order. Just need it once.
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Standing orders and protocols
Used to treat occurrences and they will be in the patient medical record.
Example:Potassium Replacement Protocols.. an order set describing how to administer potassium replacement depending on the patient blood level.
MD or LIP will just order to follow the potassium replacement protocol.
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PRN
- The Nurse will use subjective and objective data – Assessment and then document reason given and results.
- The order will specify:
- The condition to give the drug
- When to give the drug
- Route
Example:Tylenol 650 mg po Q 4 hrs PRN Temp. >101°F.
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What to do when orders change
- Orders are re-written when changes in the patient occur:
- Surgery
- Transfer between different services ie. the floor to the ICU
- Transfer to another hospital or facility.
Medication reconciliation MUST be completed
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Nursing process and Rx admin
- Assessment: objective/subjective, allergies, etc.
- Review medication order / clarify
- Reference material
- Education: The “six rights”
- Perform associated interventions
- Evaluate response
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Things to Assess before administration
- Medication record (MAR)
- Diet and fluid orders
- Laboratory values
- ALLERGIES
- Physical Assessment
- Ability to swallow
- GI motility
- Adequate muscle mass
- Adequate venous access
- Vital signs
- Body system assessment
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Subjective Assessment prior to admin
- Knowledge:
- What medications are you taking?
- What are they for?
- Expected results?
- Common side effects.
- Adherence/compliance:
- Lifestyle
- Financial situation
- Health insurance
- The Right to Refuse
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Assessment during Rx admin
- Understanding of the patient perception of why they are taking the medication
- Ability to self administer
- Swallowing…change form, thick liquids, Speech Therapist
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What should a Rx order contain?
- Correct transcription and communication
- Accurate dose calculation and measurement
- Correct administration
- Correct recording
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The MAR
- Drug order is written on the patient’s chart
- Medication order is transcribed to a Medication Administration Record (MAR)
- MAR’s contain Name, Room #, Bed #, Drug Name, Dose, and Times and Method of Administration
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Three check points when admin Rx
- Three Checks
- Before you pour
- Check the medication label against the MAR
- After you pour/prepare
- Verify the label against the MAR again
- At the bedside
- Check the medication a third time!
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6 rights of Rx admin
- Right drug/medication
- Right patient
- Right dose
- Right route
- Right time
- Right documentation
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Right med/dose
- Double check the MD / LIP order
- Do not borrow medication from other patients
- Be Aware of look alike and sound alike medications, ie diazepam vs. lorazapam
- Does this drug @ this dose for this pt make sense?
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Right pt
- Common Names->Two Identifiers
- Confused?
- What do you compare your 2 identifiers against?
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Right Route
- Double check your route:
- Oral (PO)
- Topical
- Respiratory Inhalation
- Parenteral (IM, SQ, IV, etc)
- Don't change route without LIP documented approval.
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Right Time
- Window…30 min. before and after
- Should the medication be taken with meals or empty stomach?
- What if the person is NPO for a procedure?
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Basic Rx safety
- Prepare medication for only one client at a time
- Compare order with medication available
- Calculate drug dose
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More Rx Safety
- Compare prepared medication to MAR
- Check medications at least 3 times before administering
- Take directly to patient
- 2 patient identifiers
- Complete required assessment
- Explain purpose of medication
- Assist to sitting position
- Medication and water to client
- Stay with client until all medications are swallowed – DO NOT bedside
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Oral Dose Prep
- Prepare medication for only one client at a time
- Compare order with medication available
- Calculate drug dose
- Prepare medications
- Keep unit dose in wrapper
- Don’t touch pills
- Liquids at eye level
- Fill till bottom of meniscus is at desired mark
- Narcotics: need 2 RNs to verify Rx.
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Topical Rx admin
- Mucous membranes of the mouth – buccal;
- sublingual – rapid systemic effects; local effects
- Skin administration – cleanse the skin before application. Lotions, pastes, ointments->Spread the medication around
- 3 Bears Rule – just right amount
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Enteral Rx (NG)
Check placement. Sometimes tube can migrate to lung.
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Terms for eye drops
OD=Right eye, OU=both eyes, OS=Left eye
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Vaginal admin
- Suppositories; foams; jellies; creams
- Body temperature liquefies and distributes medication
- Follow Standard precautions
- Privacy if client self-administers
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Parenteral Rx
- Medications administered by injection
- Invasive procedure:
- requires aseptic technique
- Proper administration – location, location, location
- Make sure you've got right needle (gauge) and right syringe (proper volume to accurately draw)
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Mixing Rx
- Medications must be compatible
- Total dose must be within accepted limits
- Care must be taken to not contaminate one medication vial with another medication – change needles
- Ensure that the final dose is accurate – Insulin
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Prepping insulin
- Requires check by 2 licensed personnel – you are not licensed yet
- What do you assess before giving or drawing up?
- Insulin classifications
- Regular insulin is clear and fast acting
- Other insulin is cloudy – such as NPH
- Order for drawing two insulin in one syringe:
- 1) inject air into cloudy (long lasting) vial.
- 2) inject air into clear vial (fast acting).
- 3) Turn over and draw clear into syringe.
- 4) Turn over and draw cloudy into syringe.
- 5) Check total amount before administering.
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Mixing medications – long acting and short acting insulin
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SubQ
- Abbreviated SC or SubQ
- Small amount of injectable material – usually 0.5 – 1 ml fluid
- 25-27 Gauge needle; ¼ - 5/8 inch in length
- 90º angle.
- Absorption slower than IM route
- EBP shows no need to aspirate (unless heparin)
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IM injection
- Faster absorption that SC due to increased vascularity
- Injecting medications into the blood is a risk of this route
- Needle ½ - 3 inches in length, dependent on amount of adipose tissue and patient size.
- Gauge~24ish.
- 90º angle, < 3 ml injectable amount
- Assess integrity of muscle prior to injection
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Sites for im
 - Deltoid should never get more than 1mL
- Steer clear of the glutes
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Z Track
 - 1)Pull skin laterally before injection-1-1.5 inches
- 2)Inject medication
- 3)Hold skin and keep needle in place 10 secs.
- 4)Withdraw needle and release skin
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Intradermal Injections
- Typically used for skin testing
- Necessary to see injection sites for changes of color
- Lightly pigmented, free of lesions, as hairless as possible
- Decreased blood supply = increased absorption time
- TB syringeAngle – 5º - 15º
- Checking for induration at site
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Rx Documentation after admin
- Name of medication
- Dose
- Route (site of injection)
- Date / Time
- Initials / Signature
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Questioning Rx order
- Any order that is ambiguous, unusual or contraindicated by the client’s condition.
- Contact prescriber – discuss your rationale for believing medication is inappropriate
- Use SBAR-R and state “Clarify the order..”
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What should I do if I commit a Rx error
- Immediately assess the patient’s vital signs and physical status.
- Report findings to the primary care provider.
- Notify the nurse manager of your unit and report the event surrounding the event.
- Check with your institution for agency-specific policy regarding incident reporting.
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