Nursing Process and Medication Administration Overview

Nursing Process

Research-supported framework consisting of five steps: Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation.

Assessment

Data collection (subjective/objective), medication profile (all drug use), compliance. First priority before any intervention.

Nursing Diagnosis

Patient response to problems, not disease-focused.

Planning

Goals/outcome criteria that are objective, measurable, and realistic.

Implementation

Nursing actions, drug administration, promote/minimize effects, patient education. Clarify instructions if unclear (e.g., NPO meds via IV).

Evaluation

Ongoing status of goals, patient response to drug, documentation. Check MAR first to determine if med was given.

Rights of Medication Administration

Drug, Dose, Time, Route, Patient, Documentation, Reason, Response, Refuse.

Patient Identification

Two identifiers required (e.g., name, birthdate).

Chemical Name

Drug's chemical composition/molecular structure.

Generic Name

Name given by US Adopted Names Council.

Trade Name

Registered trademark, restricted by patent owner.

Pharmaceutics

How drug forms affect dissolution/absorption.

Fastest Dissolution

Oral disintegration, buccal, oral soluble wafers, liquids, elixirs, syrups.

Slowest Dissolution

Enteric-coated tablets.

Do NOT Crush

Enteric-coated tablets, extended-release forms.

Pharmacokinetics

What the body does to the drug (Absorption, Distribution, Metabolism, Excretion).

Absorption

Drug movement into systemic circulation.

Bioavailability

Extent of drug absorption.

First-Pass Effect

Liver metabolizes oral drug before systemic availability, reducing bioavailability. IV bypasses this (higher bioavailability).

Highest Delivery/Bioavailability

IV.

Lowest Delivery/Bioavailability

Oral.

Enteral Routes

Oral, sublingual, buccal, rectal.

Parenteral Routes

IV, IM, SubQ, Intradermal, Intraarterial, Intrathecal, Intraarticular.

Distribution

Drug transport to site of action via bloodstream.

Albumin

Most common blood protein, binds drugs.

Highly Protein Bound Drugs

Low albumin = more 'free' (active) drug = increased therapeutic effect/toxicity.

Metabolism

Biochemical alteration of drug.

Main Organ for Metabolism

Liver.

CYP450 Enzymes

Liver enzymes involved in metabolism.

Enzyme Inducers

Increase enzyme production, decrease drug effect (e.g., Phenobarbital, Phenytoin).

Enzyme Inhibitors

Decrease enzyme production, increase drug effect.

Excretion

Drug removal from body.

Main Organ for Excretion

Kidneys.

Half-Life

Time for 50% of drug to be removed.

Loading Dose

Large initial amount to quickly reach peak therapeutic level.

Peak Level

Highest blood level of drug.

Trough Level

Lowest blood level of drug.

Toxicity

Occurs if peak blood level is too high.

Therapeutic Window

Range between desired response and toxic effects.

Pharmacodynamics

What the drug does to the body; mechanism of action.

Agonist

Binds to receptor, activates it, causes response (e.g., opioid analgesic).

Antagonist

Binds to receptor, blocks it, no response (e.g., naloxone).

Additive Effect

1+1=2 (combined effect equals sum of individual effects).

Synergistic Effect

1+1=5 (combined effect greater than sum).

Antagonistic Effect

1−1=0 (combined effect less than sum, or one drug cancels another).

Incompatibility

Chemical deterioration when parenteral drugs are mixed.

Adverse Drug Event (ADE)

Unintended effect from correctly administered drug.

Adverse Drug Reactions (ADRs)

Pharmacologic reaction, hypersensitivity (allergic), idiosyncratic reaction, drug interaction.

Teratogenic Effect

Harms fetus.

Carcinogenic Effect

Leads to cancer.

Pharmacoeconomics

Study of economic factors affecting drug therapy cost.

Teratogenesis

Highest risk during the first trimester of pregnancy.

Drug Transfer

Highest transfer of drugs across the placenta occurs during the last trimester.

Safest Category

Category A indicates no human fetal risk.

Most Contraindicated

Category X indicates fetal abnormalities and should not be used.

Breastfeeding Risks

Infants are at risk as drug levels in breast milk are usually lower than in maternal circulation.

Neonates & Pediatrics Pharmacokinetics

Gastric pH is less acidic, with slowed emptying and faster/irregular IM absorption.

Protein Binding in Pediatrics

Decreased protein binding increases toxicity risk.

Immature Blood-Brain Barrier

In neonates, the blood-brain barrier is immature, increasing toxicity risk.

Dose Calculation in Pediatrics

Calculated using body surface area (West nomogram) or body weight (mg/kg).

Dose Discrepancy

Contact prescriber immediately if calculated dose exceeds safe range.

Older Adults Considerations

High medication use (polypharmacy) and chronic illnesses increase adverse effects.

Physiological Changes in Older Adults

Absorption changes include less acidic gastric pH and slowed emptying.

Distribution Changes in Older Adults

Lower total body water and increased fat lead to more free drug.

Metabolism Changes in Older Adults

Aging liver has fewer microsomal enzymes and reduced blood flow.

Excretion Changes in Older Adults

Decreased GFR and fewer nephrons result in less effective drug clearance.

FDA Primary Role

Protect patients and ensure drug effectiveness.

Drug Approval Stages

Includes preclinical testing, clinical studies (Phase I, II, III), and Phase IV post-marketing surveillance.

Black Box Warning

Strongest FDA safety warning indicating serious adverse effects.

Scheduled Drugs

Controlled substances classified based on abuse potential.

C-I Drugs

Highest abuse potential, no accepted medical use (e.g., weed, heroin).

C-II Drugs

High abuse potential with accepted medical use (e.g., morphine, fentanyl).

C-III Drugs

Less abuse potential than C-II with accepted medical use (e.g., opioids + Tylenol).

C-IV Drugs

Less abuse potential than C-III with accepted medical use (e.g., Xanax, Adderall).

C-V Drugs

Less abuse potential than C-IV with accepted medical use.

Medication Errors

Preventable errors that commonly cause adverse outcomes.

Most Common Point of Error

Prescribing errors account for nearly 50% of medication errors.

Prevention Strategies for Errors

Include awareness, CPOE, bar codes/scanners, and effective communication.

High-Alert Drugs

CNS drugs, anticoagulants, and chemotherapeutic drugs that require 2nd nurse verification.

Nurse Action for Error

Report to prescriber & nursing management and document factually per policy.

Medication Reconciliation

Continuous assessment/updating of patient medication information.

Importance of Medication Reconciliation

Ensures no discrepancies between home and hospital medications.

General Admin Practices

Include hand hygiene, two patient identifiers, and checking labels three times.

Oral Meds Administration

Assess for dysphagia and implement aspiration precautions.

Buccal/Sublingual

Place under tongue/between cheek & gum; no fluids until dissolved.

Oral Disintegrating

On tongue (not under), dissolve without water, don't chew/swallow.

NG Tube Meds

Liquid form preferred; crush/dissolve solids in 15-30mL water; administer each separately, flush between meds and after (30mL). Sit patient up, HOB elevated 30 min. Use room temperature fluid for flush.

Rectal Meds

Patient on left side (Sims' position); lay down 15-20 min post-admin to avoid dislodgement.

Parenteral Safety

Never recap used needle. Use filter needles for ampules (don't inject with filter needle).

Injection Angles

ID (15°), SubQ (45° or 90°), IM (90°).

Z-Track Technique

For irritating IM meds (e.g., iron dextran).

Airlock Technique

For IM/SubQ, inject air after medication to ensure full dose and seal track.

Aspiration (Drawing Back)

Understand when/why (e.g., IM to avoid vessel). If blood drawn, withdraw, discard, restart.

IV Meds

Needleless systems, compatibility, electronic pumps. Adding meds to new bag (pharmacy preferred). Piggyback (primary bag lower).

Ear Drops

Adult (>3 yrs) pull ear up & back; Child <3 yrs pull down & back. Apply pressure to medial canthus to decrease systemic absorption.

Eye Drops

Place in conjunctival sac.

Insulin Mixing

Clear (rapid/fast-acting) first, then Cloudy (intermediate-acting).

Opioid Analgesics

Class: Opioid Agonists. MOA: Bind to opioid receptors, reduce pain. Indications: Moderate-severe pain, cough suppression, diarrhea, balanced anesthesia. Side Effects: Respiratory depression (most serious), N/V (most common), urinary retention, constipation, miosis. Interactions: Alcohol, antihistamines, barbiturates, benzodiazepines, MAOIs (increased sedation/respiratory depression). Opioid Tolerance: Larger dose for same effect. Physical Dependence: Physiologic adaptation, not addiction. Breakthrough Pain Meds: Used for sudden, intense pain despite ongoing management. Nursing Implications: Assess pain before/after; monitor vital signs (especially RR); if RR < 10-12, withhold dose, notify MD, consider Narcan. Give oral forms with food. Ensure safety (side rails). Assess bowel sounds. Change positions slowly (orthostatic hypotension). Differences: Fentanyl (100x stronger than morphine), Meperidine (neurotoxic), Hydromorphone (7-8x stronger than morphine).

Opioid Agonist-Antagonists

MOA: Bind to pain receptors, cause weaker response than full agonists. Benefit: Pain relief, but not as strong.

Opioid Antagonist

Use: Reverses opioid effects/toxicity/overdose. Key Points: Short half-life (1 hour for Narcan), so opioid effects can return. Patient will feel pain return, may experience withdrawal symptoms.