Safe and Competent Med Administration
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The use of drugs to diagnose, prevent, or treat disease is known as...
What are the three types of meds based on actions?
- 1. Diagnostic: screening for disease
- 2. Prophylactic: preventative (ex. flu shot)
- 3. Therapeutic: Treat
What 2 things do we always keep in mind about drugs?
- 1. There is no "ideal" drug, all drugs cause side effects.
- 2. The objective with drug therapy is provide maximum benefit with minimum harm.
Where do you drugs come from?
- 1. Natural sources: plant, mineral, animal
- 2. Synthesized in lab
In order for drugs to have predictable effects they need to be...
pure, and uniform strength.
Who standardizes drugs and ensures uniform quality?
What protects our health and ensures med safety and effectiveness?
What does the FDA stand for? And what do they do?
- Food Drug Administration:
- 1. sets standards for drug review/clinical trials
- 2. enforces laws related to meds
What is the Controlled Substance Act of 1970?
- 1. sets rules for manufacture and distribution of drugs with potential for abuse
- 2. categorizes drugs based on abuse potential and med usefulness
What goes on in new drug development?
- 1. $$$, lengthy process
- 2. clinical trials done mostly on men so we don't know effects on women/children
- 3. can take 2-10yrs to finish
- 4. testing cannot find all adverse effects
What exactly is the "schedule" of controlled substances? What are the categories?
- Based on abuse potential and dependence liability.
- Categories are C-I, C-II, C-III, C-IV, C-V
Describe the range of C-I to C-V.
C-I refers to illegal drugs (ex. LSD, heroin) and ranges to C-V which are controlled drugs in small amounts, OTC.
How are pregnancy risk categorized for meds?
There are 5 categories: A, B, C, D, X
What are the consequences of not following Controlled Substances Act?
Loss of job, RN license, prison
What are the 3 types of drug names?
- 1. Chemical Name
- 2. Generic Name (lower case letters)
- 3. Trade Name (upper case first letter)
When there is a conflict in meds, med on MD order sheet, MAR, and what's in pt's room, what do we do as RN?
- 1. Look up meds, use available resources
- 2. Call pharmacist
What is the best ways to find information about a med as an RN?
- 1. Pharmacology texts
- 2. Nursing drug guide
List in order of best to worst for finding out info on meds.
- 1. Pharmacology texts (most comprehensive)
- 2. Nursing drug reference books
- 3. Clinical Pharmacist (help problem solve)
- 4. Online resource (Micromedex, Rxmed.com, fda.gov)– limited in terms of nursing stuff
- 5. PDR (Physician's Drug Reference)– better left in MD's office, has chemical formula
What are the different kinds of drug dispensing?
- 1. Legend Drugs
- 2. Nonprescription drugs/OTC
- 3. Herbal products
These drugs are deemed by FDA, require supervision by MD, what are they called?
These drugs need an order when used in the hospital, FDA approved, appropriate to use w/o MD supervision, what are these drugs known as?
These drugs are not regulated by FDA or monitored. They can interact with OTC or Rx meds, and "natural" does not mean benign! What are these drugs called?
Herbal products or supplements
What is the most important thing to remember to get from the patient regarding meds?
COMPREHENSIVE DRUG HISTORY!
How are the drugs grouped?
- 1. effect on body system
- 2. symptom relieved
- 3. desired effect
The "typical" characteristics of drugs within one class is known as...
How are the drug classifications found in the Davis drug guide?
What is listed in the red box for drug classification?
- 1. Therapeutic Class: Diuretics
- 2. Pharmacologic Class: Loop Diurectics
- 3. Prototype drug: furosemide (Lasix)
There are 9 different kinds of effects drugs can have on a patient. List them.
- 1. Therapeutic effects
- 2. Side effects
- 3. Adverse effects
- 4. Toxic effects
- 5. Cumulative effects
- 6. Idiosyncratic effects
- 7. Allergic Reactions
- 8. Drug tolerance
- 9. Placebo effect
This is a desired or intended effect, the reason the drug was prescribed. What kind of effect is this?
These are predictable, unintended or secondary effects, not life-threatening (ex. nausea, vomiting, diarrhea) What kind of effects are these?
Some patients confuse these effects with allergy to the drug, what kinds of effects?
What do we do when a pt confuses side effects with allergic response to a drug?
Make sure to ask the pt exactly what happens when they take the drug. Our responsibility is to inquire about the reactions.
These effects are unintended, undesirable, and unpredictable, serious, and life-threatening! These effects can be permanent or temporary. What kind of effects are these?
What does the FDA require on adverse effects?
Black box warning
What must RNs remember to do when it comes to adverse effects?
These effects are poisonous, cause overdose, and intoxication. What are these effects called?
How do toxic effects occur?
Excessive dosing or inability of body to break down or excrete drug.
Taking multiple OTC meds with the same ingredient as the Rx can lead to...
These effects cause reversible or irreversible damage. What effects are these?
Activated charcoal is used for what?
Universal antidote for orally ingested drugs
Why do we give tylenol in the hospital instead of aspirin?
Aspirin is a big anaphylactic.
These effects are due to an unexpected drug response resulting from a genetic predisposition. They are strange and unpredictable reactions. What are these effects called?
CNS depression, nephrotoxicity, ototoxicity, GI bleeding are all examples of what kinds of effects?
A pt receives a sedative, becomes very agitated and excited. This is an example of what kind of effect?
These effects are unpredictable, immune response. What kind of effects are these?
How does medication act in an allergic reaction?
As an antigen.
Rash, urticaria (hives), and pruritis (itching) are examples of...
Mild allergic reactions
A abrupt onset, feel tingling, swelling in mouth/tongue, SOB, hyotension, tachycardia are all symptoms of...
What kind of reaction is anaphylaxis?
Severe allergic reaction
Who are the biggest culprits in allergic reactions?
Aspirin and Penicillin
What do we need to do as RNs when it comes to allergic reactions?
- 1. Get a good allergy history.
- 2. Document any allergies.
- 3. Teach to avoid re-exposure.
- 4. Wear Medic bracelet.
The amount of drug that builds up in the body. These effects are called?
These effects occur with repeated doses of a drug and the body cannot break down or excrete the drug. The intended effect becomes too strong. What are these effects called?
This requires a larger dose of the drug to maintain the given level of effect on the body. What kind of effect is this called?
This type of effect is commonly seen with opiates, alcohol, and tobacco. What are these effects called?
This effect is caused by psychologic factors, and not by physiologic properties of the drug. What is this effect called?
Are these placebo responses real?
What must we do as RN when the placebo effect might happen or is happening?
Fostering a positive attitude. Talk up the med!
When using a positive attitude about the beneficial effects of the drug what does the body use to help the med?
What are the different possible types of drug interactions?
- 1. Synergistic Effect
- 2. Additive Effect
- 3. Drug-Food Interactions
- 4. Contraindications
- 5. Pharmacokinetics
Toxicity and therapeutic failure can result from...
What happens with drug-food interactions?
Either decreases absorption, inhibits metabolism, can affect drug action.
What is an example of drug-food interaction in which the body inhibits metabolism?
Coumadin affects vitamin K
Instances where a particular drug should not be given, what are these effects called
When a pt has an allergy to the drug, is pregnant, has liver and kidney problems, this is an example of when the drug cannot be given. These are...
"What the body does to the drug" How they are absorbed, distributed, metabolized, and excreted. This is known as...
Pharmacokinetics affects decisions about...
timing and route of administration.
Pharmacokinetics can help us identify what about our pt?
It can identify if pt is at risk for changes in drug action.
What happens when a drug is absorbed into the body?
Drug binds to plasma protein. There's bound drug and free drug.
Where does the free drug go?
- 1. Storage in tissue (body fat)
- 2. Site of action (cell receptor)
- 3. Metabolism (liver, lung, GI tract)
- 4. Excretion (kidney, expired air, sweat, feces)
Onset of drug action is determined by...
rate of absorption
What are the factors that affect rate of absorption?
- 1. Route
- 2. Form, pH(some are basic, stomach is acidic (drug is acidic the drug goes slower)
- 3. Blood Flow (IM (greater) vs. Sub q)
- 4. Body surface area
- 5. Food (slow), other meds, heat and cold
In order of fastest med absorbed to slowest.
- 1. IV line
- 2. Inhalers/mucous membranes
- 3. IM
- 4. PO
- 5. Sub q
- 6. p.r.
What 4 factors affect the distribution of drugs?
- 1. Bloodstream
- 2. Membrane permeability
- 3. Protein Binding
- 4. Drug's affinity for certain areas of body
Which are the vascular organs starting with most vascular?
- 1. Liver
- 2. Kidneys
- 3. Brain
When a drug is trying to get through membrane permeability, what are we referring to?
Blood/brain barrier and placenta
What do we know about placenta unlike blood/brain barrier?
Placenta is a barrier but is not selective.
What do we know about the blood/brain barrier?
No space, harder for drugs and germs to penetrate. Also harder to treat CNS infections.
This is the degree to which drugs bind to serum proteins. It's a reversible bond. Only free drug leaves bloodstream and is able to act. What is this?
Low protein levels or competing drugs can result in....
More free drug, and may see increase drug action or toxicity.
What protein molecule is very important in the blood?
This is where drugs are metabolized and detoxified. Occurs in liver where enzymes convert drug to less active form. This is called...
active or inactive metabolites.
What happens when our liver is impaired?
Accumulation of active drug, can lead to toxicity. Greater drug effects if liver is not working properly.
What age groups won't have full functioning liver?
Elders and infants (less than 1 yr. old)
Oral doses need to be higher if given orally to get same effect. This is known as...
First Pass Effect
May need to give drug via route that bypasses GI tract to avoid...
First Pass Effect
This is where the drug and metabolites are eliminated from the body. What is the main organ?
What are other routes of excretion?
Lungs, sweat, glands, mammary glands, bile, feces
When we have impaired renal function what happens to the drug?
Increase intensity or duration of drug action.
What do we have to do if pt has impaired renal function?
May need to give smaller doses or give less frequently.
This is the time it takes for 50% of the drug to be left in the body. This is known as...
Drug Half Life
How is the drug half life determined?
Drug's rate of metabolism and excretion
For a single dose how many half lives does it usually take for the drug to be cleared from the body?
Half life determines...
A short half life =
short time between doses
Long half life =
longer time between doses
If a drug's half life is 4 hours, what does that mean?
After 4 hours there is 50% left of the drug.
How do most drugs act on the body?
Binding to cell receptors. "Lock and Key"
What are the two different kinds of receptors that drugs bind to?
What is an agonist receptor?
Activate receptor which means the drug will act.
What does an antagonist do?
Block receptors which means knock drugs off receptor site, drugs will not do their job.
Other ways some drugs can act on the body?
Simple chemical or physical interactions
Remember this about drug actions on the body:
No drug has a single action or effect!
There are 6 factors affecting drug action. List them.
- 1. Developmental factors (immature liver)
- 2. Gender (water content, fat%, hormones)
- 3. Cultural, Ethnic, Genes (beliefs, Asians need lower doses of anesthesia, Africans need higher doses of beta blockers)
- 4. Illness and Disease (cardiac output, compromised organs)
- 5. Psychological, environmental factors (Placebo effect, turn lights down, close door)
- 6. Time of Administration (1hr ac, 1 hr pc)
When administering drugs to pt what must we do?
Assess pt if too much med or too little med was given.
If dosage adjustments have to be made, who do we contact?
Initial doses of a drug are an...
What goes on in the time course of drug response?
- 1. Onset
- 2. Peak
- 3. Duration
- 4. Plateau or Steady state
This is the initial response of the drug, drug level reaches MEC (mininum effective concentration). This stage is called?
Highest plasma level with a single dose, greatest effect we will see. This stage in drug response is called?
Time during which drug levels are at or above MEC. This stage of drug response is...
Concentration of drug reached and maintained after repeated fixed doses. This stage is...
Plateau or Steady state
When there is enough drug present to produce therapeutic responses, but not so much that toxicity occurs. Above MEC but below toxicity, this is...
What is the objective of drug dosing?
Maintain plasma drug levels within therapeutic range.
Which drugs are difficult to administer safely?
Drugs with a very narrow therapeutic range.
Why do we monitor serum drug levels?
To determine if drug is within therapeutic range.
When are serum drug levels drawn?
Peak and Trough
Serum drug level is taken just after dose is given, must be kept below toxic level. This is at...
Serum drug level is done just before next dose is given, should be above MEC. This is at...
What needs to be changed after seeing serum drug level results?
Dosage or timing of meds or hold med
What's an example of plateau or steady state?
Antibiotics or BP meds given over time
Successive doses of a drug results in...
Plateau or steady state.
When a plateau needs to be achieved more quickly, a large initial dose is given. What is this called?
Smaller doses are given to maintain plateau. What are they called?
When are loading doses used? How often?
PCA pump, and usually in emergency.
What are the different forms that drugs are available in?
- 1. Capsule
- 2. Suspension
- 3. Suppository
- 4. Solution
The route and method of administration is determined by...
What must we need to know when it comes to the form of the drug?
- 1. Know how the drug comes, several different forms are available for one drug.
- 2. Know nursing implications for giving.
- 3. Check with MD if need substitute form need MD approval first* (new order)
These drugs are extended release, sustained release, long acting, containing high amounts of the drug intended to be absorbed slowly and act over a prolonged period of time. These are known as...
High Risk Forms
What must we remember when it comes to high risk form drugs?
Should never be broken, opened, crushed, or chewed.
What are the consequences of breaking, opening, crushing or chewing high risk forms of drugs?
Dose is absorbed immediately, overdose with potential organ damage or death.
What must we watch out for with transdermal delivery systems?
Heat or fever can intensify effect of patch and increase absorption rate.
What determines the best route for meds?
- 1. Med properties
- 2. Desired effect
- 3. pt's condition
If you need the route to be changed, what do we do?
This route is given via GI tract, by mouth (PO), via ng or gastrostomy tube, sublingual, buccal. This route is called...
Oral or Enteral
Benefits of po meds?
easy to take, pts preference, less $
When are most meds given po?
on an empty stomach
What's the onset and duration like for po meds? And why?
Slower onset, and longer duration because of First Pass Effect
These meds are given by injection. There are 4 different types of injections and these are known as...
What are the 4 different injections?
- 1. IV
- 2. IM
- 3. Sub q.
- 4. Intra-dermal
Benefits of parenteral?
Quicker onset and effect than oral or topical.
Which injection site has low blood supply so the absorption rate is longer?
These meds are applied to skin or mucous membranes. What are they called?
List the 5 different types of topical meds.
- 1. Sublingual
- 2. transdermal
- 3. suppository
- 4. instillation
- 5. inhalation
Eye drops are what kind of med?
Topical and instillation
What kind of effects can topical meds have?
Local or systemic.
What do we avoid with topical meds?
Open areas and non-intact skin absorb too much, while hairy skin won't absorb.
After surgery or transfer from one floor to another floor what needs to be done about med orders?
They need to be rewritten by MD.
Med orders must have 7 parts to be legal. List 7 parts.
- 1. Full name of pt
- 2. Date and time of order written
- 3. Drug name
- 4. Dosage
- 5. Frequency of administration
- 6. Route of administration
- 7. Signature of prescriber
What are the 4 different types of med orders?
- 1. Standing
- 2. PRN
- 3. Single or one-time order
- 4. Stat
This order is a drug given until order is dc or automatic cancellation per policy. What type of med order is this?
This order is a drug given as needed, based on nursing assessment/judgment, specify reason and frequency. What type of order is this?
This order is given once at ordered time and date. What type of med order is this?
Single or one-time order
This order is immediately and only once for emergency. What type of med order is this?
What core value does PRN require?
Sometimes pt has several PRN meds for one treatment, what do we do as RN?
We need to know each med and which is the best one to give based on our assessment/judgment.
When do we question an order from a prescriber?
When the order is unclear, unusual (extremely high dose) or contraindicated by pt's condition.
What do we do when we question a prescriber about an order?
Contact prescriber, discuss concerns, document when prescriber was notified, what was said, and provider's response.
When a pt refuses a med, what do we do?
Ask why, listen to pt. There might be an error, double check order, pt might need education, notify prescriber.
If pt is not present or med is not available, and we give as soon as we are able, this called...
Omitting a medication
Based on our assessment (pt is sedated) pt should not receive med, this is called...
"Holding" a med
When we don't give a med, what must we always do?
What do we assess before giving meds?
- 1. Medical history
- 2. Med history
- 3. Allergies
- 4. Functional abilities (can they hold cup or put pill in mouth?)
- 5. Current condition (drowsy? unconscious?)
- 6. Is route suitable?
- 7. Pertinent VS, lab values
- 8. pt knowledge of meds, perfect time to teach pt about their meds
What are the 6 rights to administering meds safely?
- 1. Right Med
- 2. Right Dose
- 3. Right Patient
- 4. Right Route
- 5. Right Time
- 6. Right Documentation
What are the 3 checks?
- 1. Before removing the container from supply drawer, check against MAR
- 2. When placing med in cup/syringe, check against MAR
- 3. Before giving the med to pt, check again against MAR
If RN asks you to give meds to a pt, what do we remember?
Only administer meds you prepare!
What do we document about giving meds? When?
- 1. After med is given, not before.
- 2. Parameters: AP, BP, blood sugar
- 3. PRNs
- 4. Any adverse effects noted, our action
- 5. Any meds not given (on MAR and nurse note)
What do we document about PRNs?
- 1. Drug
- 2. Dose
- 3. Route
- 4. Site
- 5. Reason given
- 6. pt response per policy
Who is the final checkpoint in the med administration process?
Most med errors are due to...
- 1. lack of knowledge
- 2. wrong drug name
- 3. incorrect route
- 4. incorrect dosage calculation
- 5. distractions
- 6. rushing thru med preparation or one patient to next patient
When an error occurs we...
- 1. Assess pt
- 2. Notify prescriber of incident ASAP
- 3. Follow up on orders received
- 4. Continue to monitor pt
- 5. Document
- 6. Report incident to manager per policy
- 7. Complete incident report (separate from charting)
When there's an error what do we NOT write in pt's chart?
"pt given wrong med"(will be in incident report), only want facts, objective findings in chart
How many meds does the average hospitalized elder take?
What physiological changes do we see in older adults that can affect meds?
- 1. absorption impaired
- 2. increased adipose tissue
- 3. decreased total body fluid
- 4. Therapeutic window narrows
- 5. Fewer binding sites
- 6. changes in blood brain barrier
What is the rule of thumb with older adults when giving meds?
Start Low.....Go Slow!
1/3 to 1/2 of elders are non adherent r/t finances, multiple drug regimens, sensory changes. This is known as...
33% of elders over 65 take more than 5 meds and use more OTC drugs than younger ppl, this is known as...
In older adults we see more_____________ r/t multiple meds, multiple health care transitions, self care deficits r/t med use.
What can we do to help older adults with their meds?
- 1. Simplify drug plan
- 2. Keep instructions clear and simple, large print
- 3. Assess if pt needs assistance to take meds
- 4. Carefully monitor pt responses
- 5. Have them drink a little fluid before taking po med to ease swallowing. Encourage intake after meds!
- 6. Review med history, OTC use on a frequent basis
When we do the 3 checks we are also doing?
When we check patient's ID band, we need how many identifiers?
2 identifiers: name and dob or hospital number
What do we check with PRNs?
Last time administered
What do we verify with controlled substances?
Verify order is current, and last time pt had med.
When does waste have to be witnessed?
When the drug is a controlled substance.
When a waste is "witnessed" what is this?
You and another RN put waste in sharps and document.
What do we remember about pouring liquid meds?
- 1. remove cap and place upside down on clean surface
- 2. Hold bottle with label against palm of hand while pouring (no spill on label)
- 3. Do not pour unused portion back in bottle
- 4. Doses less than 10 mL, use calibrated oral syringe
- 5. pour at eye level, measure at meniscus
- 6. shake suspensions (creamy)
When pouring pills from floor stock we pour into...
bottle cap. Don't touch pills! Transfer to med cup, label cup with name and room number.
When do we crush meds?
When pt can't swallow a tablet, capsule or pill.
What do we check before crushing med?
If it CAN be crushed. Some meds cannot be crushed ever!
Do we crush pills together?
No. Crush each pill separately.
When adding applesauce to crushed meds, what do we do?
Add small amount to med cup at bedside.
When pill splitting, tablets must be...
How do we split pills?
Use clean pillating device or a clean gloved hand.
After splitting pill where does it go?
Back into labeled packaging. Follow policy for remaining half pill.
When giving meds to pt, what do we say?
Name of med and purpose.
Lozenges can also be called...
What are the cautions with lozenges or troches?
Do not chew or swallow.
Besides sustained release meds that can't be crushed or chewed or opened, what other meds?
Sublingual and buccal meds are...
When applying a new transdermal patch we must...
- 1. Wear gloves, remove old patch and cleanse skin
- 2. Label new patch with date, time, initials
- 3. Place patch on different location that is dry, not hairy and no scar tissue.
- 4. press for 10 sec firmly
- 5. Note location on MAR
If a pt c/o headache with nitro patch what do we do?
Apply to site farther from head
How is the absorption and action of suppositories?
Quickly absorbed but not fast acting.
When giving suppository, what do we tell our pt to do?
- 1. Take slow deep breaths through mouth.
- 2. Remain in position for 5 min
- 3. If laxative, provide call light, and tell pt not to flush so we can assess.
What position should the pt be in for a vaginal suppository?
Dorsal recumbent position
What position should pt be in for p.r. suppository?
Left lateral side lying position
What do we offer pt getting a vaginal suppository?
perineal pad for excess drainage
How long does pt lie still after vaginal suppository?
Where do we apply eye drops? What do we avoid?
conjunctival sac (avoid cornea-extremely sensitive)
Before giving drops that were refrigerated, what do we do?
Allow them to come to room temperature.
How far do we hold dropper from eyes?
For eye drops with systemic effect what do we do?
Hold gentle pressure to nasolacrimal duct for 30-60sec
When giving eye ointment what do we do first before applying?
Discard first bead of ointment, considered contaminated.
Cold ear medications must be_____________ because can cause______________.
- warmed to room temperature
- severe dizziness or nausea
In case eardrum is ruptured what must we use when giving ear meds?
Sterile drops or solutions so no infection can occur.
For children under 3 yrs old how do we pull on ear to give ear med?
Pull pinna down and back
For adults how do we pull on ear to give ear med?
Lift pinna up and back
How far do we hold ear med from ear canal?
After giving ear med, we apply gentle pressure to where?
Tragus of ear
What does pt do after we give ear med? What about for both ears?
Lie on their side for 5-10min. For both ears they lie on one side for 10 min before turning to other side.
What position should pt be in for nose drops?
Supine position with head tilted back
What instructions do we give to our pt when giving them nasal drops?
Blow nose, and breathe through mouth.
How far do we hold dropper from nares?
After we give nasal med what does pt have to do?
Keep head back for 5 min
What position should pt be in for nasal spray?
Sit upright with head tilted slightly forward
Where do we point nasal spray in nose?
Away from nasal septum
Inhaled meds come as...
- 1. Bronchodilators
- 2. Antibiotics
- 3. Steroids
- 4. Mucolytics
What kind of systemic side effects can occur with inhaled meds?
Palpitations, tremors, tachycardia caused by albuterol
dry powder inhaler-Diskus
What do we give before steroid inhaled meds?
How do you instruct pt to use MDI?
Shake 5-6x, hold 1"- 2" away from mouth (unless have spacer) and when depress canister, simultaneously pt takes a deep breath in slowly and hold for 10 sec, then exhale slowly
If 2 puffs ordered how long does pt wait between puffs?
How long does pt wait between different inhaled meds?
What should we teach pt about their MDI to prevent using an empty canister during an acute exacerbation?
How to calculate number of inhalations in one canister.
Advair is an example of a
What would you like to do?
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