Medication Administration and the Nursing Process of Drug Therapy

“Rights” of Medication Administration

• Right medication

• Right patient

• Right dosage

• Right route

• Right time

• Right reason

• Right assessment data

• Right documentation

• Right response

• Right to refuse

Accurate Drug Administration Principles

• Follow “rights” consistently.

• Learn essential information about medications to be passed.

• Interpret the prescriber’s orders accurately.

• Read medication labels carefully – three times prior to med administration.

• Minimize abbreviation use to prevent errors.

• Calculate doses accurately.

• Avoid trailing zeros.

• Measure doses accurately.

• Use correct procedures and techniques for all administration routes.

• Learn about the patient’s diagnoses and condition in relation to medication administration.

• Verify identity of patients before administering medications using two identifiers.

• Omit/delay doses as indicated by the patient’s condition and document accordingly.

• Be especially careful when administering medication to children due to high risk of medication error.

• If medication dose is held, the provider must be notified.

Nurses’ legal responsibilities include

• Safe, accurate medication administration

• Recognizing and questioning erroneous orders

• Refusing to administer unsafe medications

• Delegating in compliance with the law

Medication Errors

• Medication errors can result in

  • Serious illness

  • Conditions that prolong hospitalization or require additional treatment

  • Death

• Common medication errors include

  • Giving an incorrect dose

  • Not giving an ordered medication

  • Giving an unordered medication

• Medications often associated with errors include

  • Insulin, heparin, warfarin, chemotherapy, pediatric dosages

Medication Orders Must include

• The patient’s full name

• Name of the medication (generic)

• Dose, route, frequency of administration

• Date, time, signature of the prescriber

• if PRN dose, must include reason for administration

Medication Order Transcription

• Typed into computer (preferred method)

• Handwritten on an order sheet

• Verbal orders

  • Signed by the transcriber, countersigned by the prescriber

• Telephone orders

  • Signed by the transcriber, countersigned by the prescriber

• Verbal and telephone orders should be last resort. If taken, the nurse must read back the order to verify heard and transcribed correctly.

Medication Order Interpretation

• Nurses must know commonly used abbreviations.

  • Routes, dosages

  • Times of administration

• “do not use” abbreviations

  • Due to frequent misinterpretation

• Illegible, seemingly erroneous orders must be clarified before administration.

Abbreviations: Routes of Drug Administration

IM: Intramuscular

IV: Intravenous

PO: By mouth, oral

SL: Sublingual

Sub-Q: Subcutaneous

Drug Preparation and Dosage Forms

• Medications may be available in various forms.

• Systemic medication forms include

  • Liquids

  • Tablets, capsules

  • Suppositories, transdermal

  • Injections

Medication Delivery Systems

• Pump delivery systems

• By mouth (PO)

  • Tablets

  • Capsules

  • Sublingual

• Controlled release

  • Enteric coated (to prevent stomach upset)

  • Maintains more consistent serum drug levels

  • Allows less frequent administration

    • More convenient for patients

  • Tablets, capsules

    • Contain high amount of drug

    • Intended to be absorbed slowly over prolonged period of time

    • Should never be broken, opened, crushed, chewed

  • Transdermal

    • Systemic absorption through skin

  • Pump delivery systems

    • External or implanted

    • Refillable or long acting without refills

      • Insulin, opioid analgesics, anticancer medications

• Topical

  • Solutions

  • Creams

  • Suppositories

  • Frequently used for local treatment

Solids: Gram (g)

• 1 milligram (mg) = 0.001 g

• 1 microgram (mcg) = 0.000001 g

• 1 kilogram (kg) = 1000 g

• 1000 mcg = 1 mg

• 1000mg = 1 g

• 1 ounce (oz) = 30 g or 30 mL

Liquids: Liter (L)

• 1 milliliter (mL) = 0.001 L

• 1 mL = 1 cubic centimeter = 1 cc

Solids: Pound (lb)

• 1 lb = 16 ounces (oz)

• 2.2 lb = 1 kilogram

Liquids: Pint (pt)

• 2 pt = 1 quart (qt)

• 4 qt = 1 gallon (gal)

• 16 oz = 1 pt = 2 cups (c)

• 32 tablespoons (tbsp) = 1 pt

• 3 teaspoons (tsp) = 1 tbsp

• 60 drops (gtt) = 1 tsp

Routes of Administration

• Oral (by mouth)

• Parenteral (injected)

  • Subcutaneous (Sub-Q)

  • Intramuscular (IM)

  • Intravenous (IV)

• Topical (applied to the skin or mucous membrane)

Medications for Injections

• Must be prepared, packaged, and administered maintaining sterility

• Typical medication containers

  • Vials (single or multiple dose)

  • Ampules

  • Prefilled syringes with attached needles

• Sterile needles

  • Various gauges (lumen size)

    • Larger number = smaller lumen

  • Various lengths, use depends on

    • Route of administration

    • Thickness (viscosity) of solution

    • Size of the patient

Equipment for Injections

• Sterile needles

  • Various gauges (lumen size)

    • Larger number = smaller lumen

  • Various lengths, use depends on

    • Route of administration

    • Thickness (viscosity) of solution

    • Size of the patient

• Needleless systems

  • Developed to prevent injury and the spread of blood-borne pathogens

• Syringes

  • Made of plastic (disposable)

  • Calibrated to measure doses accurately

  • Insulin, tuberculin syringes for small doses

Injection Sites

• Sub-Q common sites

  • Upper arms, abdomen, back, thighs

• IM common sites

  • Deltoid, ventrogluteal, vastus lateralis muscles

  • NEVER dorsogluteal

• IV common sites

  • Back of hands, forearms

Less Common Injection Sites

• Nurses may perform

  • Intradermal (into layers of the skin)

• Physicians must perform, NEVER performed by RN

  • Intra-articular (into joints)

  • Intrathecal (into spinal fluid)

  • Intra-arterial (into arteries)

Assessment

• History

  • Chronic Conditions

  • Drug Use – prescriptions, OTC, herbs, street drugs

  • Allergies to medications, herbs, foods, environmental factors

  • Level of Education and Understanding

  • Social Supports

  • Financial Supports

  • Pattern of Past Health Care

• Physical Assessment – head to toe assessment, plus weight and age

Medication History Questions

• Current medication orders

• The patient’s knowledge regarding current medications

• History of allergic reactions

• Can the patient swallow medications? Communicate verbally?

• History of herbal/dietary supplement use

Implementation

• Starts with general nondrug interventions

• Promoting health

  • Promoting healthful lifestyles regarding nutrition, fluids, exercise, rest, and sleep

  • Conscientiously performing hand hygiene, infection prevention

  • Ambulating, positioning, exercising

  • Assisting to cough and deep breathe

  • Applying heat or cold

  • Scheduling activities to promote rest or sleep

• Preventing/decreasing need for drug therapy

• Using nondrug measures to enhance therapeutic effects or decrease adverse effects

• Patient teaching

• Individualizing care

Elements of Patient Teaching

• Name, dose, and action of drug

• Timing of administration

• Special storage and preparation instructions

• Specific OTC drugs or alternative therapies to avoid

• Special comfort or safety measures

• Specific points about drug toxicity

• Specific warnings about drug discontinuation

Nurses’ Role

• Help the patient cope with the effects of drug therapy

• Patient more likely to be compliant:

  • if nurses promote drug therapy

  • if regimen is not too complicated, uncomfortable, or overwhelming

  • if they anticipate the drug will be helpful

  • if they are taught how to minimize AE

  • if they are taught environmental controls (light), safety measures (avoid driving, alcohol, sun), physical comfort measures (e.g., skin care, laxative, small frequent meals).

  • if aware of lifestyle adjustment (e.g., diuretics, laxatives, MAO-inhibitors)

Evaluation

• Part of the continuing process of patient care - observing patient response to medication

• Leads to changes in assessment, diagnosis, planning, and implementing interventions

• Remember this is a continual, ongoing process

• Evaluating for therapeutic response

  • Occurrence of AE

  • Drug-drug, drug-food, drug-other interactions

  • Therapeutic response and/or drug levels

  • Efficacy of nursing interventions

  • Patient/family teaching and understanding

Drug Therapy Evaluation Criteria

• Progress toward stated outcomes

  • Relief of symptoms

• Accurate administration

• Avoidance of preventable adverse effects

• Patient compliance

• Specific parameters measured to evaluate response to particular medications

Prevention of Medication Errors

• IOM 2000 report “To Err is Human” 44,000 estimated to actually be around 98,000 deaths in hospitals/year from medication errors

• Drug Regimen Process – prescribing, dispensing & administering

• Series of Checks

  • Nurse’s Role

  • Patient’s Role

• Reporting of Medication Errors

  • Organizational level

  • National level

Responsibilities

• The prescriber who orders the drug

• The pharmacist who dispenses the drug

• The nurse who administers the drug

  • Nurses are legally and professionally responsible for any error that occurs

  • Nurses must know how to correct drug-dosing orders into appropriate doses of available forms of a drug to ensure the right patient is getting the right dose of the right drug for the right reason.

Dosing Considerations

• Packaging

• Gender

• Weight

• Age

• Physical Condition

• Other drugs that the patient is taking

Federal Guidelines – Drug Advertising

• When the advertisement states the indication, it must also include:

  • Contraindications

  • Adverse effects

  • Precautions

• Unfortunately, these guidelines do not apply to herbs, supplements, or dietary products

• Difficult for patients to understand

  • Tiny print

  • Medical lingo

  • Advertisements speak too fast when discussing the bad

Consumer awareness: Internet sources for drug information

• Pharmaceutical company information sites

• Chat rooms with other people who are taking the drug

• Online pharmacies

• Lists of government regulations

• Research reports about the drug and its effectiveness

Protecting the Environment

• Medications in drinking water

  • Patients flushing meds, throwing them in garbage

• What does it mean for us, animals, crops

• Yearly clean out

• Take-back events

Healthcare in Crisis

• Skyrocketing cost of medical care and drugs

• Opioid epidemic

• Huge research and equipment requirements to meet consumer demands

• Rising cost of health insurance

• Earlier discharge from hospitals

• Cost considerations

  • HMO’s

  • Home Care

  • Other cost considerations

    • Insurance coverage

    • Trade name VS: Generic

Drug Abuse

• Growing problem

• Alcohol, Nicotine & Vaping

• Prescription drugs

• Street drugs

Evidence-Based Practice and Nursing Process

• Evidence-based nursing practice

  • Requires a conscientious and continuing effort to provide high-quality care to patients

    • Obtaining and analyzing best scientific evidence from research

• Scientific evidence is integrated with the nurse’s clinical expertise and the patient’s preferences and values to yield best practice.

Pharmacology & the care of Infants and Pediatric Patients

• Children differ from adults.

• Physiologic changes throughout development influence both the pharmacodynamics and pharmacokinetic actions of medications.

• Variables in absorption, distribution, metabolism, and excretion further complicate the medication process.

Pharmacodynamics in Pediatrics

• Involves drug actions on target cells

• Immature organ systems

• Body composition

• Genetic makeup

Differences between Children and Adults

• Children absorb, distribute, metabolize, and excrete drugs differently than adults

• Children’s organs are not as developed as an adult’s organs

• Pediatric Dosage Calculation

  • Fried’s Rule – child less than 1 year old

    • [Childs age in months / 150] x Adult Dose = Pediatric Dose

  • Young’s Rule – child greater than 1 up to 12 years of age

    • [Age / (Age + 12)] x Recommended Adult Dose = Pediatric Dose

  • Clark’s Rule

    • (Weight divided by 150 lbs.) x Adult Dose = Pediatric Dosage

    • (Weight divided by 68 kg) x Adult Dose = Pediatric Dosage

Toddlers and Preschoolers

• Involve this group with their medication administration by having them hold items or choosing a bandage.

• Explanations should be short and simple.

• Adults need to control administration.

School-Aged Children and Adolescents

• Explain medication use in more detail.

• Can take medications independently, but they need supervision.

• Educate on safe medication practices.

• KNOW poison control phone number.

Pharmacology & the care of Adults and Geriatric Patients

• Aging is a natural process that begins at birth.

• Age-related changes begin in the adult years (19–64 years of age).

• Older adults are people who are 65 years or older.

Pharmacodynamics in Older Adults

• Involves drug actions on target cells

• Prone to adverse drug reactions

• Beers Criteria

Prevention of Adverse Drug Effects

• Drugs that produce adverse effects in older adults

• Strategies to prevent adverse drug reactions

Medication Adherence and Aging

• Polypharmacy

• Economic factors

• Starting slow with low doses

• Asymptomatic