Medication Administration Notes
Medication Administration 1
Winona Burgess BN, MEd, RN
Topics:
Pharmacological concepts
Pharmacokinetics
Medication rights - 3 checks - 3 A’s
Scheduled oral meds (solid and liquid form)
Medication Administration 2
Legal aspects of medication administration and medication errors
PRN meds
Narcotics & controlled drugs
Topical meds (patches, eye/ear drops, nasal meds, suppositories)
Readings: Focus on oral meds; don’t read in detail about parenteral (injectable), enteral meds (nasogastric and gastrostomy meds)
Note: DO NOT NEED Box 34-19 p. 762 Astle, rectal, or inhaled meds as they will be covered in term 2 but know what they are.
Nurse Responsibilities
Interpret
Transcribe (Students are not allowed to transcribe)
Prepare
Administer
Teach (i.e., how to self-administer, side effects, etc.)
Document
Evaluate patient response to meds
MAR (Medication Administration Record) needs to have 2 initials
EPR (Electronic Patient Record) should have an icon that lets you know it’s been done properly
Student nurses can’t transcribe orders but nurses can be one of the people who initial the MAR.
"If you didn't document, you didn't do it"
Is the medication working?
Medication Names
Chemical
First name given, describes the chemical components and molecular structure
Example: isobutylphenyl propionic acid
Generic
Shortened chemical names given by first manufacturer
Example: ibuprofen
Trade/Brand
Name given by manufacturer for marketing
Example: Advil, Motrin
Chemical name provides an exact description of a medication’s composition and molecular structure, rarely used in clinical practice.
Generic name (or non-proprietary) is given by the manufacturer that first develops the medication; the generic name becomes the official name under which the med is listed in official publications such as CPS (Compendium of Pharmaceuticals and Specialties), the Canadian Formulary (CF).
Trade or brand name (proprietary) is the name under which the manufacturer markets the medication; tradename is followed by TM.
Generic Drug: copies of brand name drugs and contain the same medicinal ingredients as brand name drugs
When a drug is under patent protection, the company markets it under its brand name. When the drug is off-patent (no longer protected by patent), the company may market its product under either the generic name or brand name. Other companies that file for approval to market the off-patent drug must use the same generic name but can create their own brand name.
As a result, the same generic drug may be sold under either the generic name (for example, ibuprofen) or one of many brand names (such as Advil or Motrin).
Generic and brand names must be unique to prevent one drug from being mistaken for another when drugs are prescribed and prescriptions are dispensed. To prevent this possible confusion, the FDA must agree to every proposed brand name.
Government officials, doctors, researchers, and others who write about the new compound use the drug’s generic name because it refers to the drug itself, not to a particular company’s brand of the drug or a specific product. However, doctors often use the brand name on prescriptions, because it is easier to remember and doctors usually learn about new drugs by the brand name.
Drug Classification
Indicates the effect of medication on the body, the symptoms it relieves, or its desired effect.
Examples: Ace inhibitors, beta-blockers, loop diuretics, anticoagulants, etc.
Some meds are in more than one classification, e.g., Tylenol is an analgesic and antipyretic; Aspirin is an analgesic, antipyretic, anti-inflammatory, and platelet aggregation inhibitor.
DIN (Drug Identification Number) identifies meds.
Types of Drug Preparations
Drugs are available in many forms.
The drug form determines its route of administration.
The composition of the med influences its absorption and metabolism.
It is very important that the medication be administered in its prescribed form because it depends on how we want to use it and the effect it may have on someone.
Pharmacokinetics
Four processes encompass the pharmacokinetics of a medication:
Absorption
Distribution
Metabolism
Excretion
Each of these processes is influenced by the route of administration and the functioning of body organs.
Need this knowledge in order to time meds, select route, consider risk for alterations in med action, and evaluate response.
Absorption:
Med goes from where it enters the body into the bloodstream.
Oral = Slower; fastest: IV administration
First-pass effect affects oral medications.
The first-pass effect is a phenomenon in which a med gets metabolized at a specific location in the body resulting in a reduced concentration of the active drug reaching its site of action or the systemic circulation.
The first-pass effect is often associated with the liver, as this is a major site of drug metabolism. However, the first-pass effect can also occur in the lungs, vasculature, gastrointestinal tract, etc.
This greatly reduces the bioavailability of the med.
Bioavailability is the amount of med available to reach the target cells after metabolism to produce its intended effect.
Distribution:
The transportation of the medication in the bloodstream to the site of blood action.
Most meds tend to bind to protein. Albumin is a serum protein made by the liver.
Meds bound to albumin cannot exert their intended effect.
Individuals with liver failure, malnutrition, and older adults have lower albumin levels, which leads to more unbound or active medication available to the body resulting in an increased risk for drug toxicity.
Metabolism:
The breakdown of medication into an inactive/less active form.
Patients, especially older adults or those with chronic disease, are at risk for medication toxicity if their organs cannot metabolize medications effectively.
The liver especially is important because it degrades harmful chemicals before they are distributed to tissues; decreased liver function means slower metabolism and accumulation of the med, which is a risk for med toxicity (i.e., a small dose of narcotic in liver disease could lead to hepatic coma).
Excretion:
The process by which meds exit the body through the lungs, exocrine glands, bowel, kidneys, and liver.
Important for nurses to know how med is excreted because:
If lungs, like anesthetic, deep breathing and coughing (DB&C) will help clear anesthetic gases more quickly.
If sweat glands, like for lipid-soluble meds, need skin care due to the potential for irritation.
If bowel, then enemas suppositories laxatives increase peristalsis increasing rate of excretion and lessening time for drug effects of alternately factors that slow peristalsis (immobility, improper diet) may prolong effects of med.
Kidneys are the main organ for med excretion; therefore, if decreased renal function, they are at risk of med. toxicity (often reduced med doses in renal impairments due to this effect). Some meds are excreted through mammary glands, therefore breastfeeding is affected.
Half-life of med: It is the amount of time it takes for 50% of drug to be eliminated from the bloodstream. Another term for this is Serum half-life-time it takes for the excretion process to lower serum med concentration by half
After initial dose, each successive dose is given when the previous dose reaches half-life (I.e., pain meds better around the clock).
Medication Effects
Therapeutic Effect: The intended or desired physiological response of a medication. It is the reason it is prescribed. A medication may have more than one therapeutic effect (e.g., aspirin).
Side Effect: The unintended secondary effect, usually predictable, and is either harmless or potentially harmful. It is a common reason cited by patients as to why they stopped taking their medication. The text describes opioids causing pruritis in the absence of a rash or other allergic symptoms. Morphine is one such medication that can cause this and make it unbearable for the patient to use it for pain relief.
Adverse Effect: A severe negative response to a medication (e.g., coma) prompting immediate discontinuation of the medication.
Toxic Effect: The development of toxicity following prolonged intake of the medication or after a medication accumulated in the blood due to either impaired metabolism or impaired excretion. There may be an antidote to reverse the effects (e.g., Narcan brand name Naloxone is the generic name antidote for opioid toxicity).
Idiosyncratic Reaction: The unpredictable effects which occur when a patient over or under reacts to a medication or has a different reaction than what is expected (normal) (e.g., Benadryl which in adults usually causes drowsiness in children can cause excitement; Haldol can have severe idiosyncratic effects in older adults).
Allergic Reaction: An immune response to a medication following becoming immunologically sensitive to the initial dose of the medication. The next dose(s) are seen by the body as an antigen which triggers antibodies. Clinical manifestations may include urticaria (hives), rash, pruritis (itching), rhinitis. An anaphylactic reaction is a severe life-threatening reaction characterized by bronchoconstriction leading to severe wheezing, shortness of breath and circulatory collapse if not treated quickly.
Allergic reactions require you to immediately stop giving the drug and notify the prescriber, as well as initiate any allergic reaction protocols.
Medication Interactions
Medication interactions occur when one med modifies the action of another medication.
Meds may increase or diminish the action of other meds and alter the meds' absorption, metabolism, or elimination from the body.
Medication interactions occur commonly in those who take several medications such as the case in polypharmacy.
Polypharmacy is the use of multiple drugs or more than are medically necessary.
Polypharmacy is a concern for older adults as they tend to have more medical conditions requiring medications. It puts them at increased risk of adverse reactions.
Polypharmacy includes OTC and herbal medications as well.
A synergistic effect (greater effect) occurs when the combined effect of two medications or a medication and a substance is greater than the effects of the medications given separately (e.g., alcohol has a synergistic effect on antihistamines, antidepressants, barbiturates, and narcotic analgesics - CNS depressants).
Grapefruit juice has a synergistic effect on statins. Many drugs are broken down (metabolized) with the help of a vital enzyme called CYP3A4 in the small intestine. Certain substances in grapefruit juice block the action of CYP3A4, so instead of being metabolized, more of the drug enters the bloodstream and stays in the body longer. The result: potentially dangerous levels of the drug in your body.
If you drink a lot of grapefruit juice while taking certain statin drugs to lower cholesterol, too much of the drug may stay in your body, increasing your risk for liver damage and muscle breakdown that can lead to kidney failure.
Sometimes a medication interaction is desired. An example of when a synergistic effect is desired is in the case of some individuals with HTN who are given several meds with antihypertensives like diuretics or vasodilators which act together to control BP when one med alone is not enough.
Medication Response
The goal is to achieve a constant blood level of a medication within a safe therapeutic range (between the minimum effective concentration and the toxic concentration).
Regularly scheduled doses are required to achieve a constant therapeutic concentration of medication because a portion of the drug is always being excreted (previous dose reaches its half-life).
Time intervals of medication action: onset, peak & trough, duration
Onset: when med starts to produce therapeutic response
Peak: med reaches max therapeutic response, highest serum concentration, after peaking the serum med concentration falls progressively
Trough: point at which lowest amount of drug is detected in serum
Duration: length of time drug exhibits therapeutic response
Serum half-life: time it takes for the excretion process to lower serum med concentration by half
After the initial dose, the patient receives each successive dose when the previous dose reaches half-life (i.e., pain meds are better around the clock).
Medication Order & Reconciliation
An order is a written direction given by a nurse practitioner, physician, or other regulated prescriber regarding treatment or medication.
When it isn’t possible to get written orders, nurses can transcribe orders when given verbally. The nurse reads it back verbatim and signs the order. The prescriber must co-sign the verbal order within a certain time frame. In most places, the prescriber has 24 hours to co-sign the order. Student nurses cannot take verbal orders or transcribe orders. Unsigned orders are not valid. The signature makes the order legal.
Types of orders:
Routine orders: The most common type of order. It is carried out until the prescriber discontinues/cancels it, writes a new order, or the order has elapsed due to time or doses on order. The order can have a final date or a total number of treatments or doses.
Stat orders: An order that is to be given immediately and only one dose. Most common in emergent situations.
Single orders: Also referred to as a “one-time order”. It is an order where there is only one dose to be given at a specified time. Most common in relation to surgeries such as a preop med. This type of order does not have the urgency of a stat order. A single order can be written well ahead of time and is just given at the time designated. Example is valium 10 mg PO at 0900 hrs. This type of orders is also sometimes used before tests such as MRIs.
Standing orders: Is an order conditioned upon the occurrence of certain events (e.g., low BG, angina). It authorizes a medical professional such as a nurse to institute certain treatments or medications. All patients who meet the same criteria receive the same treatment.
PRN orders: Also referred to as an “as needed order”. This is a medication order that requires a nurse to use their assessment finding and their clinical judgement to determine if the client requires it and how to administer it. Giving PRN medications requires good pre and post assessments as well as documentation. This will be discussed in greater detail in Med Admin 2 Lecture.
There are seven essential parts to a drug order:
Patient name
Date and time order written
Drug name
Drug dose
Frequency of administration
Route of administration
Signature of prescriber
Once an order is received it needs to be transcribed and communicated to the pharmacy. This process varies depending on the type of charts being used- paper versus electronic and based on the policy of your site. Unit clerks and nurses are usually responsible for transcribing orders. As a student nurse, you are not allowed to transcribe an order.
What do you do if the order changes? You need to know what the change was and the reason behind the change.
If you are ever not sure of part of the order ask your buddy nurse or clinical instructor. The nurse should always question the primary care provider about any order that is illegible, ambiguous, unusual (e.g., high dose), or contraindicated by the client’s condition.
Med Reconciliation: Is the process of creating the most accurate list possible of all medications, including OTC by comparing the patient list with the health care providers orders. The goal is to increase client safety by providing the correct meds to the client at all transition points thus preventing an adverse drug event. Times med reconciliation needs to be done includes on admission, transfer or discharge. In the community it often includes ensuring one individual assesses all the medications ordered between all the different healthcare providers. Often what occurs is the primary health care provider is not informed of what the other specialists have prescribed which leads to polypharmacy and adverse events. Medication reconciliation needs to be done in all healthcare settings.
Nurse’s Role in Med Admin
Know the med supply and distribution system in the area you are working
For every client you need to:
Know the drug, its reason, its effect, and any nursing implications
Perform assessment to determine if it is safe to administer and if client education is required
Administer med correctly, monitor its effect, document, and respond to and report any reactions
Broadly you need to know your forms of med supply such as individual dose packets, stock supply (which is large multi-dose containers), bubble or dosette packs. Also know your distribution system such as portable med carts or automated dispensing systems such as Pyxis.
10 Rights of Med Admin
Right client
Right medication
Right dose
Right route
Right time/frequency
Right documentation
Right reason
Right to refuse
Right to client education
Right evaluation
For client identification, we always must ensure we check 2 identifiers, and this is usually name and birthdate. We ask the client their name and check the armband against the Medication Administration Record (MAR). Clients may get annoyed always asking however if you explain that it is for safety, they usually feel reassured to be asked. Other procedures will need to be followed in settings such as long-term care where there are no armbands. In this case pictures or other forms of identification may need to be used. Remember correctly identifying the client is for all our interactions with the client not just med admin. It includes bathing, feeding/providing meal trays, taking vital signs etc.
Nurses are professionally accountable for their practice. You have a responsibility to research an unknown medication prior to administration. You also need to verify orders with the prescriber that are contraindicated or are subtherapeutic or exceed recommended limits.
Last 3 of the “10 Rights”
Right to Refuse
Right Client Education
Right Evaluation
For Right to Refuse, we don’t enter the client room announcing they have a right to refuse before we have even offered the medication, but a client does have the right to refuse any medication. There are 4 things you need to do if a client refuses: you need to ask the client why they are refusing, ensure they are fully informed about the reason for the medication and the potential consequences of not taking the med, notify the prescriber, and document the refusal and reason.
Right Client Education: In order for a client to be fully informed about the med and treatment plan you are required to ensure they have been educated either by yourself or another healthcare provider. Education needs to include 4 items: the reason for taking the med, the meds action, possible side effects, and any special precautions.
Right Evaluation: once the med is administered you have to complete 4 evaluations: the effectiveness of the med, side effects, adverse reactions, and drug interactions. Do you have to evaluate after every med?…. It’s a nursing judgement often based on: length of time med has been taken, risk level of med, the acuity of the client’s health state which requires the med
Med Prep 3 Checks
First Check: When removing med from drawer (also check expiry date of med)
Second Check: After preparing the med (after dosage calculation, pouring, splitting, etc.)
Third Check: Before returning any bottle to drawer or placing med in med cup to take to client
Three checks are when the medication rights are completed “three times” during med prep
Prior to starting 3 checks on meds first check the meds to be administered on the MAR against the allergies and check for proper transcription indicated by initials of those who transcribed. FIRST CHECK: When removing med from drawer (also check expiry date of med) SECOND CHECK: After preparing the med (after dosage calculation, pouring, splitting etc.) THIRD CHECK: Before returning any bottle to drawer or placing med in med cup to take to client
7 Rights in 3 Checks
Finally, remember during prep you also must check allergies, transcription, and expiry dates
Right reason and right documentation must be checked once per med
For all 3 checks you need to include 5 rights:
Right client
Right med
Right dose
Right route
Right time
Assessment at the Bedside
Complete three “A’s” prior to med admin
Allergies: check chart, armband, and ask client
Assessment: physical assessment and bloodwork… Assessment should have been done prior to pouring but you need to state the assessment to the client prior to admin.
Armband: correctly identify client by asking client 2 identifiers and comparing 2 identifiers on MAR and armband
Med Admin Considerations
Where possible, keep meds in packaging until the bedside (maintains cleanliness and allows for med identification)
Protect client from aspiration by assisting them to a sitting position
If dealing with a client who is reluctant to take meds, prioritize by giving the most important meds first in case client does not take all of them
Never leave prepared meds unattended
Safety – Stay with the client until meds swallowed, do not leave meds at the bedside
If the client refuses, determine reason, notify physician, and document
Always prepare and administer meds going from top to bottom on the MAR to decrease the chance of missing a medication. The exceptions to this for administration is if the client may be reluctant and eventually refuse the medications. If this has occurred with the client in the past you will want to administer them based on priority with the highest priority medications given first.
Be sure to ask the client how medications went down.
May need to assess if the client swallowed meds by inspecting the oral cavity:
some elderly “pocketing” e.g., stroke, etc.
mental health depending on circumstances
stroke in anyone who may have some partial paralysis to a side of the face
Oral Medications (PO)
Contraindications:
Nausea/vomiting
GI alterations
Gastric suction
Unconscious/↓ LOC
Increased RR
When preparing:
Use aseptic technique
Do not crush:
Enteric/gel coated
Long/sustained acting
SL or buccal
Contents of caps
Oral is the easiest and most common route but slower onset and more prolonged effect than parenteral route (injectables).
Ileus is the medical term for this lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material.
The route of admin depends on med properties, desired effect, and patient’s condition (physical and mental),
Some drugs have multiple routes, Route sometimes a problem i.e., PO but patient has nasogastric tube or cannot swallow, work with prescriber to determine best route.
Not all meds can be crushed. Extended release or time-release capsules are coated to prevent med from being absorbed too quickly, before crushing check that the med can be safely crushed. If crushing meds in applesauce or pudding, do not put all meds together-need to know which meds are ingested.
For sublingual and buccal meds patients should not have anything to eat or drink immediately after.
Liquid Meds & Scored Tabs
Med volumes < 10 mL use oral syringe
Med volumes 10 mL or > pour in med cup
Pour with bottle label facing palm
To use oral syringe, pour med from bottle into med cup then draw up into syringe
If diluting meds, use caution on amount of dilution as client will need to drink all
Best to give meds with water as some juices are contraindicated with some meds
Only scored meds may be split into partial doses
When drawing the dose ensure you use appropriate equipment. For volumes > or = 10 mL pour in med cup. For volumes < 10ml a smaller more accurate device should be used such as an oral syringe (certain texts may say < 10 mL in oral syringe however it shows the nurse holding the cup at eye level- this is poor practice
Common mistake for students to not check amount in med cup once poured or to only check one tablet instead of all of them
Safe Medication Disposal
Needles and sharps ONLY
Vials, Ampules, Transdermal Patches, & all wasted Meds
Pharmaceutical waste container (blue) is for all wasted meds including vials, ampules, and transdermal patches.
Sharps container (yellow) is for all sharps such as needles and lancets.