Chapter 1-8: Medication Administration - Vocabulary Flashcards
Occurrence and Predictability of Adverse Effects
Adverse effects or side effects are predictable and common across medications.
Side effects can be dose-dependent and are often listed as the common adverse effects for a drug.
Examples of common side effects:
Erythromycin: cramping and diarrhea
Benadryl: drowsiness
Aspirin: GI upset
Some side effects are less common and require experience and education to identify.
Nurses use multiple resources for medication administration and adverse effects, including pharmacists and poison control when starting a new medication.
All drugs are potentially toxic and can have cumulative effects; drugs can accumulate if absorption is faster than elimination or if organ function is impaired.
Drug accumulation occurs when the rate of absorption exceeds the rate of elimination, especially with organ disease or failure; organs involved in metabolism play a key role.
When a drug accumulates, it remains in the body longer than intended due to slower elimination.
Medication Errors and Safety
Medication errors are preventable events that may cause inappropriate medication use or patient harm while the medication is in the control of a health care professional, patient, or consumer.
Medication errors are more common than adverse drug reactions and can be a direct cause of a reaction if administration is inappropriate (e.g., giving a drug to a patient with an allergy).
Potential error scenarios include giving aspirin to someone with an aspirin allergy leading to severe outcomes like anaphylaxis.
Medication reconciliation and education are essential to prevent errors and ensure patient safety.
Types of Reactions and Toxicities
Allergic reaction (hypersensitivity): immune-mediated response to a medication; can be mild (rash) or severe (anaphylaxis).
Tolerance: decreasing response to a repeated drug dose; higher doses may be required (e.g., cancer patients with pain).
Toxicity: drug builds up and damages organ tissues; ranges from mild (sleepiness) to severe (organ injury).
Subtypes of toxicity:
Neurotoxicity: largely irreversible; exposure to drugs, chemicals, solvents, alcohol.
Hepatotoxicity: liver toxicity; liver is highly susceptible due to first-pass exposure via hepatic blood supply.
Nephrotoxicity: kidneys; proximal tubules filter and eliminate toxins.
Immunotoxicity: immunosuppression; increases susceptibility to infections.
Cardiotoxicity: potential heart damage; more impactful in elderly and children <2 years.
Ototoxicity: affects ears/vestibular system; eighth cranial nerve can be damaged (example: gentamicin).
Idiosyncratic effects: unpredictable, unexplained, often genetically determined.
Food, alcohol, smoking, and caffeine interactions can alter drug action:
Food: some meds absorb better with food; e.g., slower absorption with calcium channel blockers and grapefruit juice; faster absorption with milk and tetracycline (reduces efficacy).
Alcohol: many prescribed meds interact with alcohol, especially CNS-active or liver-metabolized drugs.
Smoking: can decrease drug plasma levels (e.g., insulin absorption may be affected).
Caffeine: can inhibit therapeutic effects of some meds; high caffeine intake can affect CNS, heart, kidneys.
Drug interaction definitions: an alteration of action of one drug by another; can involve drug-drug, drug-food, or drug-test agents; increased risk with polypharmacy, particularly in elderly.
OTC and herbal interactions: non-prescription meds and supplements can interact with prescribed meds.
Additive, Synergistic, and Antagonistic Interactions
Additive effect: one plus one equals two; 1 + 1 = 2
Synergistic effect: one plus one equals three; 1 + 1 = 3 (testable concept)
Antagonistic effect: opposite of synergistic; combinations that reduce overall effect or counteract each other.
The instructor will provide examples to illustrate these concepts in future sessions.
Parenteral Administration and Compatibility
Parenteral (non-oral) administration has unique compatibility concerns; IV medications can crystallize or precipitate if mixed in the same line.
Examples:
Heparin and furosemide cannot be mixed in the same IV line due to precipitation risk.
TPN (total parenteral nutrition) solutions can develop crystals or precipitates.
IV compatibility information is checked using resources like Lexicomp; compatibility tabs indicate:
Green: compatible
Yellow: compatibility uncertain
Red: incompatible
If in doubt, consult a pharmacist for compatibility and safer administration planning.
Factors Affecting Drug Action and Legislation
Factors affecting drug action include:
Age/infant development (organs not fully developed yet)
Weight (dosage based on weight and pediatric calculations)
Biological sex, cultural and genetic factors
Environmental and physiological factors
Timing and route of administration
Drug dose and serum drug levels; liver metabolism can generate toxic metabolites
Cardiac perfusion can affect the QT interval and risk of arrhythmias
History of drug legislation:
1820: US Pharmacopeial Convention (USP) establishes standards; USP labels indicate identity, strength, quality, and purity.
1888: National Formulary (NF) adds public standards for drug quality.
1906: Federal Food and Drug Act requires labeling and toxicity testing; enabled drug recalls.
FDA (Food and Drug Administration) established to monitor drug manufacturing/marketing and enforce regulations.
1970: Controlled Substances Act (CSA) defines drug abuse potential and established the DEA (Drug Enforcement Administration).
USP is a scientific nonprofit that sets standards for identity, strength, quality, and purity of medications; NF is the official compendium; DEA schedules classify abuse potential (Schedule I to V; I most potential for abuse; V least).
New York State Prescription Monitoring Program: a website for providers to review schedule I/II controlled substance prescriptions to detect potential abuse across multiple providers.
Medication Administration Principles and Rights
Principles: adhere to established protocols and best practices to minimize errors and maximize therapeutic outcomes.
Indications, contraindications, and precautions must be understood for each medication; know mechanism of action to anticipate efficacy and potential harm.
Before administering, check for drug interactions; after administering, monitor effects and educate the patient.
The ATI 10 Rights and St. Joe’s 6 Rights guide safe practice; the course will first cover the 10 rights and then the 6 rights.
The 10 rights of administration (ATI):
Right patient: verify identity using two identifiers (name and MRN).
Right medication (drug): check label against the order.
Right dose: ensure correct dose and consider renal/hepatic impairment, age, weight.
Right route: ensure the route matches the order.
Right time: administer as close to due time as possible to maintain therapeutic levels; time windows often ±30 minutes (e.g., due at 09:00, administer 08:30–09:30).
Right assessment: perform appropriate assessments before, during, and after administration.
Right documentation: document promptly after administration.
Right refusal: recognize patient’s right to refuse; educate but respect decision.
Right education: clearly explain purpose, potential effects, and usage.
Right evaluation: determine therapeutic effect or undesirable response.
The St. Joe’s 6 Rights concept (essential for this course):
Right medication/drug, Right dose, Right patient, Right route, Right time, Right documentation (often reinforced with a focus on the three checks and additional safeguards).
Time format in health care: 24-hour clock (military time) used for documentation and administration; examples:
08:00 PM = 20:00
Noon = 12:00
01:00 PM = 13:00
Midnight = 00:00
Order types:
Standing order: medications are scheduled with due times and are continuous until canceled.
Single (one-time) order: given once (e.g., pre-operative prophylaxis).
PRN (pro re nata): as-needed; Latin: pro re nata; used for non-scheduled, variable dosing; may include a maximum daily dose.
Stat: immediately; Latin: statim.
Parts of a medication order:
Prescriber information and DEA number (for outpatient prescriptions; inpatient orders are entered electronically but still must be complete).
Patient information: name, DOB, date of the order.
Drug name (meloxicam in the example), dose (e.g., 15 mg), route (PO vs others), frequency (QD, q6h, PRN), date/time, patient identifier, and prescriber signature.
Brand vs generic: DAW (Dispense As Written) indicates brand; brand exchange permissible allows generic; get clarity from the prescriber.
PC: post-meal (after meals); common abbreviations include PC for after meals; need to confirm with MAR.
Verbal orders and read-back:
Verbal orders can be taken in some settings; use read-back method to confirm accuracy (repeat order back to prescriber).
Document the verbal order time and details to maintain an audit trail.
No medication should be administered without an order; in emergent situations, a scribe may document orders to ensure they are captured, but the order must exist.
Prescription Processing and Pharmacy Interaction
After the doctor writes an order, pharmacy reviews for completeness and safety before dispensing.
Verbal orders are entered into the system (e.g., Epic); the read-back confirms accuracy and creates an audit trail.
Inpatient vs outpatient processes differ (electronic MARs common in inpatient; outpatient relies more on prescriptions and pharmacy processing).
The importance of a documented trail to address potential future inquiries or issues.
Medication Handling, Preparation, and Administration Procedures
Three checks in medication preparation and administration:
Check 1 (before retrieving): verify the MAR and medication against the order; declare medications before removing from shelf.
Check 2 (during/just after removal): at the Pyxis or shelf; confirm selection matches the order and dose.
Check 3 (at patient’s bedside): in-room verification with MAR and patient identifiers; scan patient and medication labels.
In unit-dose packaging, most medications come as single-dose units; multi-dose packaging is less common in hospital settings.
Fourth check (interaction with patient): verify patient consent and willingness; do not administer medications without nurse verification.
The six rights (revisited as three checks and six rights framework) must be mastered and practiced repeatedly during labs and clinicals; the emphasis is on accuracy and safety.
Medication administration workflow considerations:
Identify patient using two identifiers; compare bracelet info to MAR.
Ensure timely administration to maintain therapeutic levels; due-time windows and clinical judgments may require rescheduling with pharmacy or physician approval.
Crushing medications: not all tablets can be crushed; some must be administered intact; evaluate alternative routes if necessary.
Pill crushers must be cleaned after use to avoid cross-contamination.
Oral medications should be administered in a recommended order: pills/tablets first, liquids second, chewables third, sublingual/buccal next, trochies last.
Some meds cannot be crushed due to extended-release or tablet integrity; if crushing is required, ensure compatibility with the chosen route and formulation.
Special considerations for administration order and patient safety:
E.g., taking a chewable aspirin with other pills may impact absorption; water is typically used to aid swallowing.
After giving a medication, educate the patient about expected effects, potential adverse effects, and what to monitor for.
Interruptions are a major source of medication errors; maintain focus and minimize interruptions during the process.
Handling patient behaviors around meds (e.g., hiding pills) requires case-by-case assessment; involve the primary nurse and consider safety and documentation for any missing doses.
If a dose is dropped or wasted, document the incident and justify the action (e.g., spilled dose); discuss with the physician and pharmacy; waste is a controlled process, especially for controlled substances.
Controlled substances require stricter safeguards:
Pyxis access requires ID and sometimes fingerprint authentication; counts are maintained to detect diversion.
Outpatient controlled substances may require ledger signatures for accountability.
The New York State Prescription Monitoring Program helps detect potential abuse by cross-checking prescriptions across providers.
Identifying a patient and maintaining safety:
Use two identifiers; address the patient by full name; compare bracelet name and MRN with MAR.
Never administer medications to a patient without proper verification and confirmation from the supervising nurse or clinician.
Quick Recap: Key Concepts to Remember
Drug effects are predictable but not universal; always educate patients about potential adverse effects and realistic expectations.
Drug interactions, including food, alcohol, and OTC/herbal interactions, can alter drug action significantly; account for polypharmacy especially in the elderly.
Tolerance and toxicity describe changes in drug response over time and potential organ damage with accumulation; monitor organ function and drug levels when indicated.
The drug development and regulatory landscape (USP, NF, FDA, DEA) shapes how drugs are tested, labeled, and controlled for safety and efficacy.
The 10 rights and 6 rights of medication administration, plus the three checks, form a robust framework to minimize medication errors.
Use of tools like Lexicomp for IV compatibility and read-back methods for verbal orders ensures accuracy and patient safety.
The clinical context (orders, pharmacy processes, patient education) requires vigilance, documentation, and interdisciplinary coordination to ensure safe and effective pharmacotherapy.
1+1=2 (additive effect) versus 1+1=3 (synergistic effect) and the concept of antagonism, which is the opposite of synergy.
Appendices and References Mentioned
Lexicomp: IV compatibility checker and drug interaction database recommendations.
USP: United States Pharmacopeia standards for identity, strength, quality, and purity of medications.
NF: National Formulary (drug quality standards).
Federal Food and Drug Act (1906): labeling and toxicity testing; recalls.
FDA: regulatory agency overseeing drug manufacturing and marketing.
CSA (1970): Controlled Substances Act; DEA oversight.
NYS Prescription Monitoring Program: state-level controlled substance monitoring system.
Terminology recap: PC (post-meal), DAW (Dispense As Written), and read-back method for verbal orders.