NP1: Exam 2

Chemical name of a medication

describes the elements of the medications molecular structure

Official name of a drug

• assigned by the U.S. adopted names council

• is usually the generic name which is simpler than the chemical name

Generic name of a drug

• is not capitalized

• often contains a prefix or suffix that helps identify the drug class

• ex.) beta blockers - propranolol, metoprolol, labetalol

Trade name or brand name of drug

• registered name by the drug manufacturer

• because one drug can be manufactured by several companies, it can have several different trade names while having a common generic and chemical name

Medication standards and regulations

• united states pharmacopeia (USP) and the national formulary (NF) are the only official authorities to establish drug standards, including the requirement that meds be free of impurities

• the FDA mandates that all meds must undergo safety testing before being released to the public

Controlled substances

• inventory must be reported to the DEA every 2 years

• if the controlled med needs to be wasted, two licensed staff members must witness the appropriate disposal and document the wasting

Pharmacokinetics

• study of how a medication enters the body, moves through the body, and leaves the body

• ADME (absorption, distribution, metabolism, excretion)

ADME in pharmacokinetics

• A → how the drug enters the bloodstream. influenced by route, solubility, blood flow to the admin site, body surface area, pt age. IV is the quickest.

• D → how the drug is transported throughout the body. influenced by chemical property of drug, effectiveness of cardiac system, ability to pass through tissue and organ membranes, extent to which the drug binds to proteins or accumulates in fatty tissue

• M → how does it get broken down, mainly liver. metabolites are a less active form that are excreted.

• E → how does the drug leave the body. most metabolites exit via kidneys, but some can be through feces, breath, saliva, sweat, breastmilk

Implications of pharmacokinetics

• The nurse monitors labs, adjusts timing, and watches for toxicity

• metabolism may be slowed in elderly, kidney & liver failure pts → toxicity, buildup

Pharmacodynamics

• process in which a medication interacts with the bodys cells to produce a biological response

• response can be systemic → nervous system, respiratory system, gastrointestinal system

• response can be local → the drug acts directly at the application site

Implications Related to Pharmacodynamics - half life

• expected time it takes for the blood concentration to measure ½ of the original drug dose due to drug metabolism and excretion.

• repeated drug doses usually required to maintain the desired drug level.

• correct spacing of doses to maintain constant drug levels and obtain therapeutic effects is based on the drugs half life

• Implication → determines dosing frequency, influences drug accumulation and steady state

Implications Related to Pharmacodynamics - Onset of Action

• the time the body takes to respond to the drug after admin

• affected by admin route, drug formation, and pharmacokinetic factors

• Implication → determines how quickly symptom relief occurs, critical in emergencies

Implications Related to Pharmacodynamics - Peak plasma level

• Highest concentration of drug in the bloodstream

• blood samples are drawn at specific times after admin on basis of half life

• Implication → greatest therapeutic effect, highest risk for adverse effects or toxicity

Implications Related to Pharmacodynamics - Trough

• Lowest concentration of drug before the next dose

• samples for trough levels are drawn just before admin of scheduled dose

• Implication → determines if drug levels stay therapeutic, prevents underdosing or resistance

adverse effects

• severe, unintended, unpredictable drug reactions

• may occur after one dose such as an allergic reaction or may develop over time

• these must be reported by PCP to the FDA

toxic effects

• result from a med overdose or med buildup in the blood due to impaired metabolism and excretion

• can lead to organ damage. monitoring kidney and liver function is vital to prevent this

allergic reaction

• unpredictable immune responses to meds

• minor reactions include rash, itching, inflamed nasal passages causing swelling and clear discharge, and hives

• always check pt allergies before administration

Anaphylactic shock

• immediately stop the med that caused this

• start administration of epinephrine, or IV fluids, steroids, or antihistamines while providing respiratory support

• require pts to remain in the facility for 20-30 minutes to be monitored for possible severe allergic reaction

• pts who have had severe allergic reactions to a med need to wear an ID bracelet that identified the drug

Idiosyncratic reaction

• unpredictable pt response to med

• can be overresponse, underresponse, or abnormal reation

• ex) the med is supposed to make you sleep but instead you are hyper

Medication interactions

• occur when the drug action is modified by the presence of certain food or herbs or another med

• interaction can alter the way the med is absorbed, metabolized, or eliminated

Synergistic effect

2 drugs taken together produce a stronger effect than either drug taken alone

Antagonism

• occurs when the drug effect is decreased by taking the drug with another substance, including herbs

• ex) antibiotics can lessen the effect of BC, grapefruit juice alters absorption of statins

Drug incompatibility

• mixing meds in a solution that causes precipitation or combining a drug with another drug that causes and adverse chemical reaction

• compatibility must be verified before mixing or administering meds with a syringe or through IV tubing

• if non-compatable meds are prescribed, they must be administered separately, such as flushing the IV tubing between medications.

Factors to consider when selecting an OTC

• clearly understand the desired effect and potential adverse effects of all ingredients

• understand possible allergic reactions

• potential interactions with other meds and herbs

• warnings

• dosage and directions features

• FDA ‘choosing the right OTC medicine’ for selecting OTC meds

• vitamin, herbs, and OTC use should be documented as pt history

Prescription meds

• med order must have pt name, date and time order is written, name of drug, dosage, route, frequency of administration, signature of prescriber

• Informatics - MAR includes pts full name, full name of med, admin time, dose, route, frequency, site of admin for parenteral meds, and nurses initials and signatures. must document refusal or hold for a med

Enteral Route - oral

• oral most common (PO)

• make sure pt swallows

• should not be given to pts with difficulty swallowing or with mental or cognitive issues

• oral meds can be given via nasogastric, gastric, intestinal, jejunal tubes → check tube placement before admin to prevent aspiration/clogging.

• meds that cannot be crushed for admin thru tube → enteric coated, time release, sublingual, buccal

Enteral Route - buccal

• meds are placed against the mucus membrane of the cheek until completely dissolved

• absorbs small amounts of med quickly thru oral mucosa

• meds administered this way are antiemetics and opiate main meds

• make sure to rotate cheeks

Enteral route - sublingual

• meds are placed under the tongue to dissolve

• absorbs small amounts of med quickly thru oral mucosa

• ex - nitroglycerine for chest pain

• avoid eating/drinking until absorbed

Topical medications - instillation

• liquids and ointments can applied directly to eyes

• suppositories can be inserted into rectum and vagina

• eye socket, ear, vagina, bladder, rectum can be flushed with a solution

• spray can be applied to throat

• absorption is affected by the vascularity of the application site requires additional patches every 24hrs

• transdermal patch → topical preparation to deliver med slowly for systemic effects

Oral medications

• easiest and most convenient route

• pts ability to swallow, level of consciousness, gag reflex, nausea and vomiting need to be assessed prior to prevent aspiration

• nurse makes sure pill is swallowed and has pt drink fluids to make sure pill is not lodged in esophagus, eating a small amount of food helps get lodged food move thru esophagus

• anti fungal meds may need longer contact with mucus membranes “swish and swallow” - should be last oral med administered

• tubes are flushed before and after admin with 15ml sterile water

• have the pt sit upright as possible to prevent aspiration - pt should remain with the head elevated for at least 30min after admin

• gastric suction should not be used for 20-30min after admin

Transdermal meds

• absorbed thru skin for systemic effect

• skin site is cleansed and dried before admin

• previously placed patch must be removed prior to new one

• placement sited rotate to avoid skin irritation

Ophthalmic instillation

• eyedrops can be used for diagnoses or to anesthetize the eye

• each pt has an individual bottle of eye meds

• do not touch the tip of the dropper or tube to pts eye

• eyedrops use → tilt pts head back, have pt look up, pull pts lower eyelid down to form pouch, have the pt blink several times, maintain slight pressure on the inner canthus to prevent loss of med thru tear duct

• Ointments use → squeeze ¼ in strip of ointment from the tube into lower eyelid, moving from the inner canthus to the outer canthus, instruct pt to close and roll eyes around, inform pt med may cause temporary blurred vision

• irrigation use → fill sterile irrigation syringe with warm sterile irrigation solution, place basin bowl below pts face and offer towel, hold pts eye open with the nondominant hand, hold syringe 1in above the eye and at an angle from the inner canthus toward outer canthus, flush eye until the solution in eye is clear

• Disks use → position the disk of a gloved fingertip, place disk in the conjunctival sac and position the lower eyelid over the top of it, removing the disk: expose disc by lowering lower eyelid, used gloved index finger to pinch the disk and break the suction with the eye, do not allow pt to rub the eye after med has been inserted

Otic instillation

• use ear drops at room temp to prevent nausea pain, dizziness

• tympanic membrane damaged → preform procedures with sterile technique

• meds should not be forced into ear canal → could rupture tympanic membrane

• eardrop use → have pt lie with the ear to be treated in uppermost position, pull the pinna back and up, release the pinna and press on the tragus several times to prevent loss of med and reduce systemic effects wait 5 min before placing in the other ear

• irrigation use → fill sterile syringe with warm sterile solution, place a basin at face level and under ear offer pt towel, clean the pinna and meatus, straighten the auditory canal by pulling the pinna back and up, flush ear until foreign particle is removed, place cotton loosely in the ear, have pt lie down on another towel placed under the head, pt should be in side lying position with affected side down to drain excess fluid, remove cotton 10-15 minutes after

Nasal meds

• administered by drop or nebulizer

• nurses uses medical asepsis when administering

• meds used excessively → increased HR rebound effect that increases congestion

• administering → tilt pts head back slightly or lie in supine position with head tilted back, pt breathe out mouth, insert device 1/3in into one nostrile have pt plug other nostril, keep pts head tilted back for several minutes

Inhaled meds

• MDI and dry powder inhalers are hand held devices that a pt activates before inhaling

• each time device is pressed → specific dose is released, med absorption is rapid

• spacers can be used with MDI to trap the med and allow inhalation over several breaths → helpful for children or pt who cannot inhale slowly

• nebulizers → used to aerosolize meds into find droplet or gas form for delivery to lungs

• bronchodilation is a desired local effect

• inhaled steroids can cause systemic effects → rinsing mouth and oral care should be preformed

• assessment before and after admin includes breathing status, breath sounds, RR, use of accessory muscles

• pt education → determining when the inhaler is empty and needs to be replaced

• number of doses in the container be divided by number of doses pt takes in a day, pt should keep record of doses to obtain a refill before it runs out

Vaginal medications

• suppositories are refrigerated because they melt at body temp

• pts should be offered absorbent pad/ undergarment

• tampons should not be used after med admin

• administration → pt empty bladder before, pt lie on back with knees flexed or lie in left lateral recumbent position, lubricate applicator using water soluble gel, cleanse vaginal opening, use rolling motion inserting downward and backward, pt to remain in this position for 5-10 minutes

Rectal meds

• thinner than vaginal suppositories

• often stored in fridge

• unwrapped suppository is placed above the internal anal sphincter and against the mucus membrane for absorption

• for laxative effect, suppository needs remain in the rectum for 15-45 min

• enemas are used to treat pts with high potassium levels or to pass stool, small volume ones contain 100ml solution and need to be retained for 5 minutes or longer, large volumes ones contain 1000ml and need to be retained as long as possible

• administration → position pt on left side with upper knee flexed, insert the rounded end first, insert 3-4inches, pt to remain in left lateral position with butt pressed together for 5-10 min, if laxative the pt should remain supine for 35-45 minutes

Parenteral meds

ID → shallow injection into the dermal layer just under the epidermis

SQ → injection into the subcutaneous tissue just below the skin

IM → injection into a muscle pf adequate size to accommodate the amount and type of medication

IV → injection or infusion directly into the bloodstream via a vein

Syringes

• common types are standard, tuberculin, insulin

• as the gauge number decreases, the diameter of the needle increases

• needle lenghts vary from ¼ to 3in

• standard syringes are 1-, 3-, 5-, 10-ml sizes

SQ syringe and needle

typically administered with a 1ml syringe and a 3/8 to 5/8 inch, 25 to 31 gauge needle

IM syringe and needle

usually admistered with a 3ml syringe and a 1 to 3 inch, 19 -25 gauge needle

ID syringe and needle

1ml tuberculin syringe with a short ¼ - 5/8 in needle

Insulin syringe and needle

• U-100 syringes are calibrated in units and mL and supplied in the sizes: 30 units, 50 units, 100 units, each with a 26-31 gauge needle

• may be administered by a prefilled pen which combines the insulin container and syringe

Filter needles or straws

• used when meds are being withdrawn from an ampule

• the filter traps glass fragments

• must be replaced with a regular needle before injecting the med into pt

Needleless delivery systems

• significantly decrease stick injuries and exposure to blood borne pathogens

• available for IV med admin and require special tubing ports and blunt tip cannulas that attach to the syringe in place of a needle

• some needleless systems allow syringes to connect directly to the IV tube port

SQ site of injection

• abdomen

• lateral aspects of the upper arm and thigh

• scapular area of the back

• upper ventrodorsal gluteal area

ID site of injection

• inner forearm

• upper arm

• across the scapula

IM site of injection

• ventrogluteal

• vastus lateralis

• deltoid

• infant → vastus lateralis

• children → vastus lateralis or deltoid

• adult → ventrogluteal or deltoid

before admin of a med the nurse should

• check pts MAR or PCPs prescription

• review diet and fluid orders

• review relevant lab values

• preform brief physical assessment

• safe practice → only accept written orders, in emergency verbal orders are ok but need to be entered into pts MAR asap, SRNs are not allowed to transcribe written orders. nurse to clarify orders that are difficult to read, do not contain all info or contain unfamiliar abbreviations

Medication errors

• nearly 75% of med errors are a result of distraction

• “any preventable event that may cause or lead to inappropriate med use or pt harm while the med is in the control of the HCP, pt, or consumer

• the nurse is the pts last line of defense against mistakes

• nurses can inform other employees that they are going to admin a med and ask for help → can ask a UAP to ask the pt if they need anything beforehand

• if a med error occurs → nurses priority is to determine the effect on the pt and intervene to offset any adverse effects, immediate and ongoing assessment, notify prescribing PCP, initiation of interventions and ongoing assessments as prescribed to offset reactions, document the event as soon as patient is is assessed and stable

Measures to reduce errors

• replace handwritten med orders with a computerized provider order entry system and use a barcode system when admin a med

• barcodes verify that the drug and pt match and that adverse interactions are unlikely

• tech advances like barcodes, MAR, CPOE, IV smart pumps and automated dispensing systems help eliminate nearly all med erros

ac

before meals

pc

after meals

bid

two times per day

(bi)

tid

three times per day

qid

four times per day

q

every

SL

sublingual

Top

topical

P

after

C

with

S

without

Liq

liquid

Susp

suspension

C

cup

CC

cubic centimeter

Fl

fluid

minim

m

dram

dr

1c

8oz

1 glass

8 oz

1 in

2.54 cm

1kg

2.2 lb

1 oz

2 tbsp

1 oz

30 ml

1 pint

16 oz

1 lb

16oz

1 tbsp

3 tsp

1 tsp

5ml

1 cm

10mm

1kg

1,000,000,000mcg

1m

100cm

1mt

15 gtt

1tsp

16gtt

Six rights of med admin

• right drug → verify when taking the drug out of the dispensing unit, when comparing it with the MAR, at the bedside before admin

• right dose → verify that the calculation is correct, strength is correct, dose prescribed is appropriate for the pt

• right time → admin meds at the appropriate time frame or as specified, admin with correct frequency, use correct time system

• right route → admin via prescribed route only, check compatibility, need for dilution, and rate of admin, when more than one syringe is needed label the syringes with the drug name and dose, some drugs may be cut or crushed

• right pt → use barcode scanning system, verify at least 2 pt identifiers against the MAR, never use pts room or physical location to verify

• right documentation → documentation is completed after admin to reflect the admin, refusal, or withholding, note any adverse effects, include the communications with other HCP, include the indications that necessitate admin of PRN meds and the pts response to meds

Med admin safety

• additional checks before admin → prescriber order, pt allergies, med expiration date

• never admin med that you did not prepare

• med admin cannot be delegated, even to other professionals

• never leave the med unattended at beside

• appropriate vital signs are taken before and after admin

Pt concerns

• if the pt questions or refuses → stop the admin, verify the info, and proceed accordingly

• pt has the right to refuse the med

• nurse investigates the pts reasons for refusing to ensure the pt understands the risks of refusing

• prescriber needs to be notified of the pts refusal

• documentation of refusal should include → pts concern, info provided by the nurse, name of the prescriber who was notified

Three safety checks

1. confirming that the label of the med matches the MAR, performing any necessary dosage calc, review pts allergies, verify expiration date

2. preparing the med and again checking the label against the MAR

3. recheck the med label for the final time against the MAR before opening the package at beside

patient rights

• right to be informed of the name, purpose, and potential side effects of meds

• right to refuse a med

• right to have an accurate med history taken by a qualified person

• right to receive meds in accordance with the 6 rights of med admin

ADPIE in med admin

A → pt allergies, preg or breastfeeding status, collect pt med history including any prescriptions, OTC, alternative therapies, physical exam results, lab results. responses to med assessment questions should be documented

D → analyzes subjective and objective data: lack of knowledge, constipations, impaired health maintenance

P → develop pt goals and plans care based on the nursing diagnoses, assessment of the pts ability to perform needed tasks and realistic expectations of achieving these goals

I and E → implements the plan of care. evaluate effectiveness of those implementations

Ampules

• ampules range from 1ml -10ml, colored ring around narrow neck is where the glass is rescored to be broken

• ampule neck is cleaned with an alcohol swab

• protective sleeve or sterile 2×2in gauze is used when breaking the ampule top

• ampule is discarded into a sharps container along with any unused med

Vials

• needle attached to a syringe is used ti pierce the rubber seal ad draw the proper amount of fluid into the syringe

• an adapter for use with a needleless cannula may be used if multiple doses are to be drawn from the vial

• if more than 1 dose is to be used from the vial, the vial must be labeled with the date and time it is opened and it initials of the RN opening it

• the med is stored in a locked med cart or room and used or discarded within a designated time to protect from possible microbial growth in the vial

• multi dose vials should be designated to one pt whenever possible

• the rubber seal is cleaned with alcohol every time the vial is used

Reconstituting powdered meds

• some powdered meds are stored in a vial and are reconstituted by adding a liquid or diluent

• sterile normal saline and sterile distilled water are common diluents used to reconstitute

• Act-o-vial system → the med powder and diluent are in two compartments of a single vial, separated by the rubber stopper. to do this, the nurse depressed the stopper to combine the diluent and med, gently mixing the solution

Prefilled cartridge or syringe

• cartridge is placed into a reusable injection device or holder. care is taken to lock the cartridge into the injection holder to stabilize it during admin

• before injection, the cartridge is cleared of air and excess med

• after admin, the cartridge is removed from the holder and placed in the appropriate disposal container. the holder is retained and reusable

• some meds supplied in cartridges are withdrawn using a different syringe and is admin with that syringe. the transfer of med from a prefilled cartridge to a different syringe is done if a needless system is in place or a safety needle is available for use

• no air is injected into the cartridge before the med is withdrawn

• prefilled syringes → a single dose of med is in a syringe with a needle attached, excess air or med may need to be expelled from the syringe, some prefilled syringes contain air that should not be removed before admin (like enoxaparin)

Mixing meds in one syringe

• if two meds are compatible they can be mixed in one injection if the total amount of fluid is within the guidelines for admin into a parenteral site

• incompatible meds may become cloudy or form precipitate when mixed

• compatibility is determined through drug info and pharmacy resources

• when preparing med from a vial and an ampule → the nurse prepares the med from the vial first and then uses the same syringe and a filter needle or straw to withdraw the med from the ampule

• when mixing meds from two vials → the nurse takes care to ensure that the final dose is correct, aseptic technique is used

ID administration

• often used to admin local anesthetics, test for allergies, test for TB exposure

• drugs are absorbed slowly thru the dermal tissue and small amounts med can be instilled

• inner forearm, upper arm, scapular area

• 15 degree angle

• 1ml tuberculin syringe with a 25 to 27 gauge ¼ - 5/8 in needle

• pressure or massage should not be applied to the site

• location of injection is documented

Subcutaneous administration

• insulin and heparin are commonly admin this way

• absorption is slow with a sustained effect

• aspiration is not required for SQ

• the volume of the med admin should not exceed 1ml

• abdomen, lateral aspects of upper arm and thigh, scapular area, upper ventrodorsal gluteal area

• injection site should be rotated

• 45 or 90 degree angle

• 3ml syringe with a 25 - 31 gauge, 3/8 to 5/8 in needle

• nurse pinches 2 in of tissue between 2 fingers and inserts at 90 degree angle

• if less tissue is available, nurse pinches 1in of tissue and inserts at a 45 degree angle

• the length of the needle should be half the depth of the pinched skin fold

Intramuscular administration

• IM injections are rapidly absorbed if the pt has adequate circulation

• when preparing, the nurse should consider the volume of the fluid, med being admin, injection technique, site selection, syringe and needle selection

• ventrogluteal, vastus lateralis, deltoid

• injection volume varies from 1ml to 5ml

• dorsogluteal site should not be used but if used → slow aspiration for blood over 5-10 seconds before admin of med

• primary site for pts over 7mo is the ventrogluteal → free of major blood vessels, nerves, fat, lower rates of injury. safest site for all adults, children, and infants, recommended for volumes greater than 2 mL

• deltoid site lies close to radial nerve and brachial artery, care must be taken

• vastus lateralis site → used for adults and children, use middle third of muscle for injection

IM Z track method

• are used for meds that discolor tissue or are irritating to the tissue

• this technique seals the med into the muscle, with no tracking of the med into the SQ tissue when needle is drawn

• after the med dose is prepared, a new needle is placed on the syringe so that no med is on the outside of the needle

• large muscle site is selected, such as ventrogluteal

• site is wiped with an antiseptic cleaner, overlaying skin and SQ tissue are pull 1in laterally to the side

• the skin is held taut in this position with the nondominant hand, the needle that is inserted deep into the muscle, and the med is injected

• the needle is held in place for 10 sec to allow for med dispersion

• a zig zag path is left that seals the med into the muscle

IV administration

• Most rapid onset of action

• The most dangerous method for medication administration → infiltration, extravasation, thrombophlebitis, phlebitis

• Confirm placement of the IV line prior to drug administration

• Scheduled flushes required each shift for saline lock (heplock) to keep patent.

• assessment data needed before admin includes pt allergies, med or IV solution incompatibilities, amount and type of diluent needed for the med, rate of med admin

• monitor integrity of the site only