Foundations

• 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

• 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

• Prep. and distribution
• Asses and evaluate Rx therapy needs
• Provide education about Rx ae to the pt.

• Assess and prescribe the medication
• Computer..most accurate
• Written
• Telephone
• Read BackVerbal..ONLY in Emergent Situations
• Repeat Back

• 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

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.

These medication orders will need renewed after a specific period of time.  Pharmacy will notify the prescriber.

• STAT…emergent…high priority…obtain and administer
• NOW…slightly lower priority…complete within an hour.

One time order. Just need it once.

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. 

• 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.

• 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

• Assessment: objective/subjective, allergies, etc.
• Review medication order / clarify
• Reference material
• Education: The “six rights”
• Perform associated interventions
• Evaluate response

• 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

• 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

• Understanding of the patient perception of why they are taking the medication
• Ability to  self administer
• Swallowing…change form, thick liquids, Speech Therapist

• Correct transcription and communication
• Accurate dose calculation and measurement
• Correct administration
• Correct recording

• 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

• 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!

• Right drug/medication
• Right patient
• Right dose
• Right route
• Right time
• Right documentation

• 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?

• Common Names->Two Identifiers
• Confused?
• What do you compare your 2 identifiers against?

• Double check your route:
• Oral (PO)
• Topical
• Respiratory Inhalation
• Parenteral (IM, SQ, IV, etc)
• Don't change route without LIP documented approval.

• 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?

• Prepare medication for only one client at a time
• Compare order with medication available
• Calculate drug dose

• 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

• 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.

• 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

Check placement. Sometimes tube can migrate to lung.

OD=Right eye, OU=both eyes, OS=Left eye

• Suppositories; foams; jellies; creams
• Body temperature liquefies and distributes medication
• Follow Standard precautions
• Privacy if client self-administers

• 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)

• 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

• 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.

• 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)

• 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

• 
• Deltoid should never get more than 1mL
• Steer clear of the glutes

• 
• 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

• 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

• Name of medication
• Dose
• Route (site of injection)
• Date  / Time
• Initials / Signature

• 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..”

• 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.