NRN11 - Exam 1 Seminar (Render)

What must an order contain to be considered valid?

• Patient Identification

• The Drug

• The Delivery

• The Logistics

• Authorization & Timing

Valid Order - Elaborate on Patient Identification.

• Patient Full Name

• Date of Birth (DOB)

• Medical Record Number

Unique Patient Identifiers: What does “John/Jane Doe” mean? “Public"?

• “John/Jane Doe” = Unknown Patient

• “Public” = Protect identity from the public.

What do you do if two patients have the same full name and date of birth?

Refer to their Medical Record Number (MRN)!

Valid Order - Elaborate on The Drug.

• Medication

• Strength

  • Double Check: Is the dose safe for the indication?

Valid Order - Elaborate on The Delivery.

• Route

• Frequency

  • QS = Daily (Usually 0900)

  • QHS = At Bedtime (Usually 2100)

  • BID = Twicw a Day (Usually 0900 & 2100)

Valid Order - Elaborate on Logistics.

• Amount to Dispense

• Refills

Valid Order - Elaborate on Authorization & Timing.

• Provider Signature

• Date Written

• Time Written

Reminder: Never administer a medication without an order or administer if it is invalid!

Types of Orders: Scheduled

Def: Routine Administrations

Types of Orders: PRN

Def: As Needed

Types of Orders: Stat

Def: Used for life threatening or urgent situations.

What should you do if a STAT order is not complete/ready on time?

If a stat order IS NOT complete:

• Escalate the situation (talk to the pharmacy)!

• Communicate with the Provider!

• Document a Progress Note: “Spoke to ____. Will continue to follow-up.”

Types of Orders: One-Time

Def: A SINGLE Prescribed Dose

How are orders put in? - Computerized Provider Order Entry

Def: Feeds direct, standardized data into Automated Dispensing Cabinets (e.g Pyxis).

*Ensures controlled, traceable, and legible medication access.

What does the CPOE flag?

• Allergies

• Unchecked Labs (Double-Check)

• Contraindications (can be missed)

How are orders put in? - Verbal Orders: What should you do?

• Document the following:

  • T.O/V.O (Telephone Order/Verbal Order)

  • Drug/Medication

  • Dose

  • Route

  • Reason

  • Frequency

  • Who gave the order?

  • Date

  • Time

*Include Progress Note: Dr.____, Phone Number, “Read Back & Verified)

*Order MUST be signed within 24 hours.

First Medication Check: Pulling Medication from Dispensing System (Pyxis)

• Read Label:

  • Medication Name

  • Strength

  • Expiration Date

• Ensure Integrity:

  • Bar Code MUST NOT be Tampered

  • Package MUST BE Sealed

Second Medication Check: Comparing it to the MAR (Medication Administration Record)

*Hold up the medication up against the MAR and compare:

• Name of Medication

• Expiration

• Intactness/Integrity

• Double-Check Dosage Calculations

Third Medication Check: At the Bedside

*Same as second medication check except performed at the beside.

Fourth Medication Check: Before Throwing Packaging Away (Double-Check It)!

Before you throw out the medication packaging, double-check it!

Rights of Medication Administration: List the PRE-ADMINISTRATION Rights!

• Right Reason

  • Why is the patient recieveing X medication?

• Right Assessment

  • Assess Vital Signs, Labs, [Rely on CURRENT Information]

  • Utilize Drug Book

Rights of Medication Administration: List the ADMINISTRATION Rights!

• Right Patient

  • Use Patient Identifiers

• Right Medication

• Right Dosage

• Right Route

• Right Time

Rights of Medication Administration: List the POST-ADMINISTRATION Rights!

• Right Documentation

• Right Response

  • Reassess Patient

• Right Education

  • Teach Patient—-Explain alternatives if refusal occurs.

• Right to Refuse (does NOT apply to confused patients)

Routes of Administration: Enteral

• Oral

• Enteral Tubes

Routes of Administration: Mucosal

• Sublingual

• Buccal

*FAST ABSORPTION

Routes of Administration: Parenteral/Injectable

• Intravenous (IV)

• Intramuscular (IM)

• Subcutaneous (SubQ)

• Intradermal

What are common student medication errors?

• Failure to Monitor Labs & Vital Signs

• Failure to Check For New Orders

• Wrong Route of Administration

List the types of medication errors.

• Near Miss (caught before harm occured; REPORT IT!)

• No Harm

• Caused Harm

• Death

Reasons for Medication Errors: Active Failure (Sharp End)

Define. Provide Examples.

• Def: Unsafe acts committed by frontline clinicians in direct contact with the patient or system.

• Ex:

  • Misprogramming an IV

  • Skipping a Barcode Scan

  • Misreading a Prescription Label

*Immediate Consequences, Easily Identifiable

*Point of Impact

Reasons for Medication Errors: Latent Failure (Blunt End)

Define. Provide Examples.

• Def: Pre-existing system weaknesses embedded in the environment, equipment, or organizational policy.

• Ex:

  • Look-Alike Packaging

  • Understaffing

  • Rigid Software UI

  • Low Environmental Lighting

*Hidden accidents waiting to happen; Delayed Consequences; Often Provoke Active Failures

*Landmines Waiting to Happen

What drug administration policies have been instituted to help prevent errors?

Drug administration policies that have been instituted to help prevent errors include: Federal Food, Drug, & Cosmetic Act (1938), Durham-Humphrey Amendment (1952), the Kefauver-Harris Amendment (1962), and the Food & Drug Administration Modernization Act (1997).

Documenting Practices - Standard Practices

• Document accurately and legibly.

• Use Black or Blue Ink ONLY

• Document immediately after administration!

Documenting Practices - How do you handle errors?

• To fix a mistake: Cross through the entry with a single line, mark “ME” (Mistaken Entry), and add your initials.

• NEVER: Use a Pencil

• NEVER: Use white-out or attempt to obscure previous text.

Medication Reconcilliation: What is it? When is it performed?

• Def: Ensuring continuity of care by assessing medications——a process used by the health care team where the current medication orders are compared to patient report, the patient’s medical record, and prescriptions that may have been in place before the transition of care.

• DONE ON:

  • Admission

  • Any Point of Transfer

  • Discharge

  • Daily Medication Reconcilliation

Define: Pharmacology

The branch of medicine and biology concerned with the study of drug action, where a drug can be defined as any man-made, natural, or endogeneous (within the body) molecule that exerts a biochemical and/or physiological effect on the cell, tissue, organ, or organism.

Elaborate the role of the doctor.

• Assesses the Patient

• Prescribed Rx (Drug, Dose, Route, & Frequency)

• Uses Clear, Unaminbigous Language

Elaborate the role of the pharmacist.

• Verifies the Order

• Checks for Interactions & Allergies

• Prepares or Dispenses the Drug

• Provides Guidance

Elaborate the role of the nurse.

• Applies the 11 Rights of Medication Administration

• Administers the Medication

• Actively monitors and educates the patient.

Define: Generic Drug Name

• Usually appears in lowercase and is listed first in a drug reference:

  • Ex: warfarin (Coumadin)

  • Ex: acetaminophen (Tylenol)

• There is generally one generic name for a medication—-it often reflects or derives from the active ingredient or chemical name.

• It is not owned by a specific drug company.

Define: Brand Drug Name

• Usually capitalized and listed after the generic name.

• Is owned by a pharmaceutical company.

• One generic medication may have multiple brand names.

Define: Pharmacokinetics

What the body does to the drug.

*Pharmacokinetics doesn’t follow the ADME pathway; instead of going through the first-pass effect, some drugs bypass these steps and directly enter the bloodstream.

Pharmacokinetics: Absorption

• What does the step entail?

• What factors should you take into consideration?

• Def: The movement from the site of administration into the bloodstream.

• Factors:

  • Route of Administration

  • Blood Flow

  • Lipid Solubility

  • pH Levels

  • Patient Factors

  • Presence of Food or Other Medications

Rank the routes of administration from fastest to slowest absorption.

  1. IV

  2. Inhalation

  3. Sublingual/Buccal

  4. Injection: Intramuscular (IM)

  5. njection: Subcutaneous (SubQ)

  6. njection: Intradermal (Ex: TB Test)

  7. Rectal or Systemic Topical Routes

  8. Oral

  9. Vaginal, Eye, & Ear Medications

Define: Distribution

• What are factors that impact distribution.

Movement from the bloodstream into body tissues and fluids.

Factors:

• Blood Flow to Tissues

  • Areas with HIGHER blood flow receive medication FIRST.

• Capillary Permeability

  • The ability of medication to cross capillary walls to reach tissues.

• Plasma Protein Binding

Distribution Physiological Barrier: Blood-Brain Barrier

• Selectively Permeable

• Allows only selected molecules to cross, including certain lipid-soluble substances, gases, and small water-soluble molecules.

• Medications intended to act in the brain must be designed or selected to cross this barrier.

Distribution Physiological Barrier: Placental Barrier

• Semi-Permeable

• Any medications and substances in the maternal bloodstream can cross to the fetus.

• Pregnancy status must be assessed before administering medications, and fetal safety must be considered.

Metabolism

• What is the primary site of metabolism? Other sites?

• What is the first-pass effect? What happens?

• Primary Site: Liver

• Can also happen in:

  • Kidneys

  • Lungs

  • Stomach

  • Intestines

  • Plasma

• First-Pass effect: the process in which the liver metabolizes a medication before it reaches the general circulation.

  •  The liver:

      - Breaks down the medication.

      - Separates active medication from inactive ingredients and metabolites.

      - Removes substances the body does not need.

      - May inactivate part of the medication before it is reactivated or released into circulation.

Define: Metabolites

By products of drug breakdown; TOXIC—-need to be excreted.

Define: Bioavailability

The amount of active medication that reaches the systemic circulation.

*Oral medications may have substantially reduced bioavailability because of the first-pass effect.

Liver Function

• What labs are used to monitor liver function?

• What does it mean if only one is high?

• What does it mean if both are high?

• Liver Function Tests: ALT & AST

  • ALT = Alanine Aminotrasferase

  • AST = Aspartate Aminotransferase

• AST & ALT are often monitored together.

  • Low ALT/High AST - Indicates non-liver damage (e.g heart).

  • High ALT/High AST - Indicate Liver Damage

Liver Function Test: Alanine Aminotransferase

• What organ(s) they are specific to?

• What is the normal range?

• What do elevated levels mean?

• Specific to: Liver

• Normal Range: 8-40

  • Low levels are normal.

• Elevated Levels:

Liver Function Test: Aspartate Aminotransferase (AST)

• What organ(s) they are specific to?

• What is the normal range?

• Specific to:

  • Liver

  • Heart

  • Other Muscles

• Normal Range: 10-40

  • Low levels are normal.

  • Elevated levels suggest heart or muscle damage.

True/False: Impaired liver disease does not alter metabolism, drastically increasing the risk of dangerous drug interactions and toxicity.

False

Explanation: Impaired liver disease DOES alter metabolism, drastically increasing the risk of dangerous drug interactions and toxicity.

What are clinical manifestations of liver failure?

• Elevated Hepatic Enzymes

• Jaundice (esp. in skin and eyes)

• Dark Urine

• Itching (caused by retained toxins)

• Abdominal Distention

• Chronic Fatigue

• GI Upset (esp. Nausea/Vomiting)

Define: Excretion

• What are sources of excretion?

• What factors should a nurse consider?

• Def: The removal of metabolic waste products, via kidneys, lungs, liver, skin, or bowels.

• Nursing Considerations:

  • Age

  • Kidney Function

  • Drug properties

Kidney Function

• What labs are used to monitor kidney function?

• Blood Urea Nitrogen (BUN)

• Creatinine

• Potassium

Mnemonic: “If you want good BUNS, hit the gym.”

• Pre-workout Snack: Bananas (Potassium)

• Pre-workout Supplement: Creatine

Kidney Function Test: BUN

• What does it measure?

• What is the normal range?

• What do abnormal levels mean?

• Stands For: Blood Urea Nitrogen

• Measures the waste product of protein metabolism; occurs primarily in the liver and is transported to kidneys.

• Normal Range: 10-20 mg/dL

• Elevated Levels: Impaired Kidney Function

  • Critical: >50 mg/dl

Mnemonic: BUNions on Limbs —> 10 Toes: 20 Fingers/Toes Total

Kidney Function Test: Creatinine

• What does it measure?

• What is the normal range?

• What do abnormal levels mean?

• Measures the waste product of muscle metabolism; filtered by kidneys.

• Normal Range: 0.5-1.2 mg/dL

• Decreased Levels:

  • Low Protein Diet

  • Sever Liver Disease

  • Low Muscle Mass

• Elevated Levels:

  • Impaired Kidney Function

  • CHF

  • Dehydration

Mnemonic: CreatiNINE —> 0.9 is in the middle of 0.5 and 1.2.

Kidney Function Test: Potassium

• What is the normal range?

• What do abnormal levels mean?

• Normal Range: 3.5-5.2 mEq/L

• Decreased Levels:

  • Nausea/Vomiting

  • Diarreah

• Elevated Levels:

  • Renal Failure

  • End-Stage Renal Disease

  • Heparin
    NSAIDS (e.g Iburprofen & Naproxen)

• *Elevated K+ levels can cause arrhythmias.

Mnemonic: Think" “Bananas” usually come in bunches of 3-5!

Diabetes: Most patients die from complications of diabetes, not the disease itself.

• List some complications of diabetes.

• Retinopathy (eye damage, vision lossO

• Neuropathy (nerve damage, loss of sensation)

• Nephropathy (Kidney Damage)

• Cardiovascular Damage (damage to heart & vessels)

• Delayed Wound Healing

• Organ Failure

Define: Pharmacodynamics

What the drug does to the body——how it turns on, turns off, promotes, or blocks cellular functions.

Define: Affinity

How strongly a drug binds to the receptor site.

Pharmacodynamics: Agonist Mechanism

What is it? Result?

• What is it? A drug binds to receptors and activates them.

• Result: FULL ACTIVATION

  

Pharmacodynamics: Antagonist Mechanism

What is it? Result?

• What is it? Antagonists block receotors activation by agonists.

• Result: NO ACTIVATION

Pharmacodynamics: Agonist/Antagonist Mechanism

Result?

• Result: LESS ACTIVATION

Define: Trough

• When is the trough usually drawn?

• The lowest concentration level of a drug in the bloodstream.

• Drawn: 30 minutes before the next dose.

Define: Peak

• When is the peak usually drawn?

• What do you do if the peak is too low?

• What do you do if the peak is too high?

• Def: The highest concentration level of a drug in the bloodstream.

• Drawn: 1-1.5 hours after medication treatment is done (VARIES)!

• Too Low:

  • Increase Dose

  • Increase Frequency

• Too High: (Above Therapeutic Window—-too much in the system)

  • Decrease Dose

  • Space Out Frequency

  • Antidote (LAST RESORT)!

    

True/False - Troughs and peaks are drawn for all medications.

False

Explanation: Troughs and peaks are usually drawn for toxic medications—-measuring peaks and troughs keeps medicaions within the therapeutic window.

Define: Half-Life

What are considerations nurses should take into account?

• Def: The time it takes for a concentration of a drug to decrease by 50% in the bloodstream.

• Nursing Considerations:

  • Timing of Doses

  • Toxicity

  • Non-Compliance

  • Patient Teaching

Short Half Life v. Long Half Life

Short Life:

• Works Fast, Leaves Fast

  • Frequent Dosing Required

  • TOXICITY—Stopping the drug clears it from the system quickly!

  • Missed Dose —> Rapid Drop in Therapeutic Window

• Ex:

  • IV Morphine

  • IV Analgesics

  • Anesthesia & Sleep Aids

Long Life:

• Slow to Build, Slow to Clear

  • Less Frequent Dosing Required

  • Easier to maintain a steady therapeutic level.

  • TOXICITY—-Takes longer to clear.

• Ex:

  • Psych Meds

  • BP Meds

  • Cholesterol Meds

  • Birth Control

Side Effect v. Adverse Effects

Describe the difference.

• Side Effect: Unwanted, Generally Tolerable

  • Ex:

    • Nausea

    • Hiccups

    • Diarrhea

    • GI Upset

  • Adverse Effect: Serious, Possibly, Life-Threatening

    • Ex: Anaphylaxis

    • Sever Hypotension

    • Severe Hair Loss

    • Steven-Johnson Syndrome

Steven Johnson Syndrome (SJS)

• What causes it?

• What are hallmark s/s?

• What interventions do you perform?

• Cause: A severe adverse reaction possible with occur any medication.

• S/S:

  • Early Flu-Like Symptoms

  • Skin Blistering

  • Peeling, Raw Skin

  • Mucous-Membrane Involvement

  • Dehydration

  • Sepsis/Pneumonia

  • Multiple-organ failure

*Can appear even after years on the same drug.

• Intervention: All medications may be stopped, then reintroduced one at a time.

True/False: Anticoagulants dissolve existing clots.

False

Explanation: Anticoagulants decrease or prevent clot formation, they DO NOT dissolve an existing clot—thrombolytics (e.g alteplase) do!

Anticoagulant: IV Unfractionated Heparin

• When is it administered (acute v. chronic)?

• How is it administered?

• What are the primary labs you monitor?

• What is the therapeutic target?

• What is the antidote?

• What do you do if the dose is subtherapeutic?

• Administration: Acute Settings

• How is it administered: Starts as IV Bolus —> Continuous Infusion.

• Lab(s):

  • PTT

  • Platelets

• Therapeutic Target: PTT: 46-70 sec

• Antidote: Protamine Sulfate

• Clinical Action if Sub-Therapeutic: Increase Dose

Lab Value—Partial Thromboblastin Time (PTT)

• What does the lab measure?

• What is the normal range?

• What is the therapeutic range?

• What do you do if PTT is low/normal?

• What do you do if PTT is too high?

• Measures: The time (in seconds) it takes for your blood to clot.

• Normal Range: 21-35 sec (NO HEPARIN)

• Therapeutic Range: 46-70 sec

• Clinical Actions:

  • Too Low/Normal: Increase Dose (thins blood)

  • Too High:

    • Hold Medication

    • Adjust Dose

      • Decrease Dose

      • Decrease Administration Frequency

    • Antidote: Administer Protamine Sulfate

    • Monitor:

      • CBC

      • Hemoglobin

      • Hematocrit

      • Platelets

      • Signs of Bleeding

SAFETY RULE for PTT: Two nurses must verify an IV bolus, continuous Infusion. or rate changes.

Anticoagulant: Lovenox (Enxoaparin)

• When is it administered (acute v. chronic)?

• How is it administered?

• What are the primary labs you monitor?

• What is the therapeutic target?

• What is the antidote?

• What do you do if the dose is subtherapeutic?

• Reminder: Low-Molecular-Weight Heparin (LMWH)

• Administration: Often used when a patient is more stable.

• How is it administered: Subcutaneous (SubQ)

  • Never massage the injection site (risk of increased bruising or bleeding).

  • Consider: Renal Function

• Lab(s):

  • Platelets

  • Do not routinely monitor PTT.

• Therapeutic Target: Platelets: > 150,000

• Antidote: Protamine Sulfate

• Clinical Action if Sub-Therapeutic: Assess Platlets

Lab Value—Platelets

• What does the lab measure?

• What is the normal range?

• What are abnormal ranges—-what do they mean and what do you do?

• Measures: A platelet count in a blood test shows the number of tiny cell fragments in your blood that help form clots to stop bleeding.

• Normal Range: 150,000-450,000

  • 400,000 —> 200,000 is still considered normal by range, BUT A 50% drop from baseline requires immediate provider notification!

• Abnormal Ranges:

  • Thrombocytopenia: < 150,000 (blood too thin/excessive bleeding)

  • Thrombocytosis: > 450,000 (blood to thick)

Anticoagulant: Warfarin (Coumadin)

• When is it administered (acute v. chronic)?

• How is it administered?

• What are the primary labs you monitor?

• What is the therapeutic target?

• What is the antidote?

• What do you do if the dose is subtherapeutic?

• Administration: Chronic/Maintenance

• How is it administered: Oral (PO)

• Lab(s):

  • PT

  • INR

• Therapeutic Target: INR: 2.0-3.0 (Standard)

• Antidote: Vitamin K

• Clinical Action if Sub-Therapeutic: Increase Dose (PT: 1.5-2x Normal)

Therapeutic level on Coumadin should be 1.2-2x higher than normal; if low/normal, the dose must be increased.

Lab Value—Prothrombin Time (PT)

• What does the lab measure?

• What is the normal range?

• What are abnormal ranges—-what do they mean and what do you do?

• Measures: How many seconds it takes for a blood sample to form a clot.

• Normal Range: 11-13 sec (0.8-1.2)

Lab Value—Internationalized Normalized Ratio

• What does the lab measure?

• What is the normal range (no tx)?

• What is the standard therapeutic range?

• Measures: How long it takes for your blood to form a clot.

• Normal Range: 0.8-1.2 (NO WARFARIN TX)

• Standard Therapeutic Range: 2.0-3.0

What can cause a patient’s INR to decrease? What does this mean?

• Vitamin K Vegetables

  • Avocados

  • Kale

  • Spinach

• CoQ10

• Green Tea

• Result: Thicker Blood

What can cause a patient’s INR to increase?

• Coumadin

• Alcohol

• Aspirin

• Result: Thinner Blood

What is the difference between PT and INR?

PT measures the actual seconds it takes blood to clot, which can vary by lab/reagent. INR standardizes that PT value into a ratio so results are comparable across different labs and machines.

Antiplatelet: Aspirin

• When is it administered (acute v. chronic)?

• How is it administered?

• What are the primary labs you monitor?

• What is the lower dose used for? Higher dose?

• Administration: Chronic/Maintenance

• How is it administered: Oral (PO)

• Lab(s):

  • Platelets (Most Important)

  • CBC

  • Bleeding

    • *Hold & notify if bleeding occurs.

• Typical Dosing:

  • 81 mg (“Baby Aspirin”) - Myocardial Infarction/Stroke Prevention

  • Higher Dose - Pain Relief

Describe the difference between anticoagulants and antiplatelet?

Anticoagulants (Warfarin, Heparin) interfere with clotting factors. Antiplatelets (Aspirin) stop platelets from clumping together in the first place. Different mechanism, different monitoring, different use cases.