Medication Management

the right medication

verifying that the medication being administrated is the correct one

right patient

positively identifying the right patient

right dose

checking the MAR/ prescription to ensure the corrcect dosage is administered

right route

confirm the correct route. prevents harmful effects and ensures optimal drug absorption

right time and frequency

check when the medication should be given and ensure it aligns with the last dose

right response

make sure the medication leads to the desired effect

right documentation

record the time, dose, route and any relevant information in the care record

right to refuse

respect the patients decision if they decide to refuse, after at thorough discussion about the risks and benefits

right education

provide clear and concise information about the medication being taken

right reason

confirm the rationale for medication. what is the patients history? why are they taking the medication?

what are the 10 rights

1. right medication

2. right patient

3. right dose

4. right route

5. right time and frequency

6. right response

7. right documentation

8. right to refuse

9. right education

10. right reason

2.4L to mL

2400mL

4g to micrograms

4,000,000 mcg

300mL to L

0.3L

20mg to micrograms

20,000 mcg

1g to mg

1000mg

600mg to grams

0.6g

20 micrograms to mg

0.02mg

1.75L to mL

1750mL

medication dose equation

• want over got, times what its in

• units must be the same

• eg. you want to give 200mg of a medication liquid that is 250mg/5mL - 200/250×5= 4mL

fluid rates equation

• volume to be infused over time (Hr/Min) equals mL’s (Hr/Min)

• eg. you are giving 1000mLs in 10Hrs (600Mins) - 1000/600Mins = 1.6mL/Min

infusion time equation

• volume to be infused over rate equals time

• eg. 1000mLs/80mLs (per Hr) = 12.5 (12Hrs 30Mins)

drop rate equation

• total fluid in mLs over total hours x 60 (convert to minutes) x giving set calibration

• eg. person is prescribe NaCl 1000mLs to be infused over 8 hours. giving set of 20mL calibration - 1000mL/480Mins(8×60)x20mL = 41.6 drops/ Min

which World Health Organisation tool would you use if you were trying to plan an effective pain management drug strategy

WHO analgesic (pain relief) ladder

what are the three steps of the WHO analgesic ladder

1. mild to moderate pain: non-opioids - aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol

2. moderate to severe pain: mild opioids (codeine) with or without non-opioids

3. severe pain: strong opioids (morphine), with or without non-opioids

what must be done whenever analgesia is administered

• Evaluate

• Reassess

• Document

what do you need to consider if overnight analgesia is neglected

• escalating pain

• difficulty getting pain under control in the morning

• insomnia

ten important medication considerations/ tips

• think WHO if you don’t know what to do

• evaluate post medication administration

• night time analgesia

• trouble shooting guidelines

• other nursing measures

• paracetamol regularly

• tramadol

• initiate bowel regime

• pain relief early

• sedation

what are some side effects of opioids

• Itch

• Sweating

• Confusion

• Hallucination

• Bronchospasm

• Loss of appetite

• Chest wall rigidity (fentanyl)

• Dependence, tolerance, addiction

• Immunosuppression (long term morphine)

• Hyperalgesia (large long term doses morphine)

• Peripheral vasodilation causing some hypotension

what compilations can occur when giving opioids

• Pinpoint pupils (opioid action on the oculo motor nerve)

• Respiratory depression (reduction of the responsiveness of brainstem respiratory centre to CO 2 )

• Seizures (from the pethidine metabolite norpethidine, at high doses)

• Urinary retention. (Morphine inhibits the voiding reflex and

  increases the tone of the external sphincter)

• Increasing sedation (opioids are centrally acting in the nervous

• system)

• Nausea and vomiting (direct stimulation of the chemo trigger receptor zone)

• Constipation from slowing down the gut and also increasing water retention from colon

resources of trouble shooting guidelines (management of complications)

• PCA/ Epidural charting

• IPS handbook

• Naloxone protocol

A 90yr-old pt has had a laparotomy this morning. meds have all been given, she is sleepy but still uncomfortable, what do you do?

ask HO or Reg for a review

which is a medication on the first step of the WHO ladder

paracetamol

which analgesic should not be given with ondansetron?

tramadol - because ondansetron decreases the analgesic effects of tramadol

if your pt is taking opioids what should be apart for their routine therapy

• bowel chart/ regime

• probiotics

• increase fluid intake

• plenty of fruits and fibrous foods

how much time is needed to provide analgesia via PO

30Mins for IR PO

how much time is needed to provide analgesia via sub-cut

20-30Mins

how much time is needed to provide analgesia via PCA or IV

10Mins

what does a 0 represent on a sedation score chart

alert and awake

what does a 1 represent on a sedation score chart

mild sedation, easy to rouse

what does a S represent on a sedation score chart

asleep, easy to rouse

what does a 2 represent on a sedation score chart

moderation sedation, easy to rouse, unable to remain awake

what does a 3 represent on a sedation score chart

difficult to rouse - decreased respiratory rate now recognised as late and unreliable sign of respiratory depression

what is the first sign exhibited by a pt receiving too much opioid

sedation

features of naloxone

• works within seconds

• very short half life 20-30Mins

• reversal of analgesia

• close ops required post administration

features of vascular access devices (VAD)

• into vein

• avoiding points of flexion

• being aware of pH and osmolality

• dwell time

• dressings

• care and management

• complications

types of VAD’s

• subcutaneous (SC)

• peripheral IV catheter (PIV)

• midline

• central venous access device (CVAD)

• centrally inserted central catheter (CICC)

• femorally inserted central catheter (FICC)

• peripherally inserted central catheter (PICC)

• tunnelled cuffed - centrally inserted central catheter (tc-CICC)

• totally implantable venous access device (TIVAD)

• dialysis catheters (permacath, vascath)

what is an epidural

a very fine plastic catheter which is placed though the skin into the epidural space within your spinal canal (up to 6 weeks)

what is intraosseous

IO vascular access refers to the placement of a specialised hollow bore needle through the cortex of a bone into the medullary space for infusion of medical therapy and lab tests

what is intrathecal

the placement of an intrathecal catheter is a minimally invasive procedure aimed at releasing drugs directly into the subarachnoid space for the control of pain in cancer and non-cancer conditions

what is ommaya

ommaya reservoir is a ventricular access device with an intraventricular catheter system for the purpose of chronic access to the intrathecal space for medication administration and access to cerebrospinal fluid

A patient requires 4 mg of Morphine IVI. Morphine is available as 10mg/ml. How many mls will you draw up?

0.4mLs

Gentamicin 360 mg is prescribed. Gentamicin is available as 80mg/2ml. How many mls will you draw up?

9mLs

Haloperidol 3 mg IVI is charted. Haloperidol is available as 5mg/ml. How many mls is required?

0.6mLs

Frusemide 70mg IVI is charted. Stock dose is 20mg/ml. How many ml would you give?

3.5mLs

Atropine 0.6 mg = ?mcg

600mcg

0.01gm = ? mg

10mg

Gentamicin 360mg = ?g

0.36g

Digoxin 125mcg = ? mg

0.125mg

Augmentin 1.2gm = ?mcg

1,200,000 mcg

Digoxin 125mcg = ? g

0.000125g

Prescribed dose – 50 mg/kg Patient’s weight – 79 kg What is the dose required?

3950 mg

The patient is charted 15mg/kg/day. The patient weighs 75kg. How much is the total dose per 24 hours?

1125 mgs

1.2 mg to mcg

1200mcg

1.3g to mg

1300mg

500mcg to mg

0.5mg

0.04mg to mcg

40mcg

20mcg to mg

0.02mg

600mcg to g

0.0006g

2g to mcg

2,000,000mcg

450mL to L

0.45L

64mL to L

0.064L

4.3L to mLs

4300mLs

A 1L bag is to be infused over 6 hours. Calculate how many mls per hour the patient will receive.

166.6 mls → 167 mls rounded

How many ml/hr would a patient receive if they were to have 500ml of fluid infused over 6 hours?

83.3 mls 83 mls rounded

Your patient is prescribed a 1000ml infusion of Sodium Chloride 0.9% with 40 mmols of Potassium to be given over 6 hours. Using a buretrol giving set, calculate the drops per minutes he will receive.

166.6 drops per/ min rounded

what is dygoxin

a cardiac glycoside that increases the force of myocardial contraction and reduces conductivity within the atrioventricular (AV) node.

what is augmentin

amoxicillin penicillins are antibacterials that attach to penicillin binding proteins to interrupt cell wall biosynthesis, leading to bacterial cell lysis and death.

what is gentamicin

Aminoglycosides are bactericidal antibiotics that inhibit protein synthesis

what is atropine

a antimuscarinic drug that competitively blocks the action of acetylcholine on muscarinic receptors. This decreases salivary and respiratory secretions, reduces vagal effects of bradycardia and AV node blockade, and counters the effects of anticholinesterase drugs or poisons (including organophosphates)

what is haloperidol

an antipsychotic, selectively antagonises dopamine receptors with a high affinity for post-synaptic D2 receptors, reducing dopaminergic neurotransmission in the mesolimbic pathway resulting in a reduction in hallucinations and delusions.

what is codeine

it is dependent on hepatic biotransformation to morphine (a full opioid agonist) for its analgesic effect. Opioid agonists bind to opiate receptors in the brain and spinal cord resulting in inhibition of the ascending pain pathways thus altering the perception and response to pain

what is the definition of pharmacokinetics

The study of the movement of a medication through the body. where it enters the body and is absorbed, where it is distributed to reach its site of action, how it is metabolised and how it is excreted

four stages of pharmacokinetics

1. absorption

2. metabolism

3. distribution

4. excretion

three main ways for medication to enter the circulatory system

• Enteral administration - through the gastrointestinal tract

• Topical administration - directly to the site for action

• Parenteral administration - directly into the bloodstream

who can prescribe

• the medical practitioner

• nurse practitioners

• nurse prescribers

• midwives with prescribing rights

• dietician

• dentist

what is the prescribers role

The prescriber enters a medication order into an electronic medication management (eMM) system, onto a medication chart in the patient's health record, or onto a legal prescription pad.

who can dispense?

pharmacist

Who can administer medications?

• registered nurse

• enrolled nurse

• health care assistants

• doctor

• pharmacist

• support worker

when must you do medication safety checks prior to administration

Check the label of the medication to the prescription 3 times prior to administration

1. when you select container

2. as the medication is being dispensed

3. when returning the container for storage

class A drugs

• methamphetamine

• heroin

• zopiclone

• cocaine

class B drugs

• amphetamines

• morphine

• opium

class C drugs

• tramadol

• codeine

• benzodiazepines

• ketamine

Standing Orders

A standing order is a written instruction issued by a medical practitioner, dentist, nurse practitioner or optometrist. It authorises a specified person or class of people who don't have prescribing rights to administer and/ or supply specified medicines and some controlled drugs. The intention is for standing orders to be used to improve patients timely access to medicines.

Nurse Initiate (NIM)

• non-prescribed medications that can be administered by a nurse when the situation arises

• standing orders take priority

• prescription not required

• follow organisation policy

• usually a specified list will exist

• recommended only registered nurses initiate

Pro Re Nata (PRN)

• also known as 'as needed' or 'as required'

• administrator uses assessments, judgemental and experience to determine when to give, dose to give and weather route is suitable

• often will have an indication and maximum dose

• frequency ranges should be avoided eg. Q4 - 6hrly

• requires administration date, time, dose and route

• time administrated is to be documented in 24hr only

Single (one only)

• prescriber prescribes medication to be given only once at a specific time

• some medication can be prescribed for multiple different times

• requires time commenced and time completed (24hr)

Statum (stat)

• Prescribed in once only medication section

• signifies once only immediate administration

• often (not always) written in emergency's pending emergency's

• some requirements as once only medications

Regular

written by prescriber for a prescribed time, amount of doses or until cancelled

Verbal order

• No real legislation to outline or guide verbal order use

• MOH have some guidelines

• RN to record name of prescriber, recipient, date and medicine order and have order signed by prescriber within 48hrs

The process:

1. write order as its being given

2. read it back to prescriber

3. colleague to hear the order and repeat to prescriber

4. write the verbal order in specific section

5. resolve any discrepancies before phone call ends

6. enter administration as usual with normal checks

7. Te Whatu Ora require prescribers signature ASAP or within 48hrs