Chapter 30: Medications

Medication order

There are  several types of order that are prescribed which are:

●       Routine order- are carried out as specified until it's canceled by another order.

●       Standing orders- medications that are administered in certain situations and have specified limitations.

●       PRN order: medication that is given when the patient requests or requires it.

●       One-time order- the medication is carried out only once at a specific time. Medication to be administered before surgery is an ex of one-time order.

●       Stat order- only given once and carried out immediately. Such as medication of antihistamine or bronchodilator.

●       Patient-controlled analgesia order (PCA)- allows the patient to control administration of an intravenous analgesic for pain management.

Consist of seven parts:

1.      Patients name and secondary identifier such as date of birth, medical record number.

○        The full name is used, the middle name or initial should be included to avoid confusion. In the record it should include the patient’s name, secondary id #, and the primary care providers’ name. A secondary id may be the date of birth (include the day, month, and year)

2.      Date and time the order is written

➢     Helps to prevent errors of oversight as different nurses take charge of the patients’ care.

➢     State law determines the length of time an order for a narcotic remains valid, so the starting date and time must be clearly documented.

3.      Name of drug to be administered

➢     it is stated in the order, either by the trade (brand) name and/or by the generic name.

➢     Use the generic name since it is considered safest and is required by many health care facilities.

4.      Dosage of drug

Can be stated in either the metric or the household system. The metric system has been adopted internationally and is the most widely used and it’s the safest measurement system. Household equipment such as teaspoons and tablespoons. To prevent errors the best practice is providing patients with commercially available oral syringes, droppers, and cups since they are easy to read.  

5.      Route by which the drug is to be administer

The route also affects the absorption of the drug. See table 30-2 to see the different types of routes. 

6.      Frequency of administration of the drug

➢     usually stated in standard abbreviations in the medication order. For common abbreviation see Box 20-3 (pg.524)

➢     Pharmacy departments, facility policy and nursing service determine the hours at which routine drugs are given.

➢     Administer drugs punctually as ordered.

➢     Drugs should be administered within a half-hour before or after the indicated hour. Ex a drug to be administered at 0900 can be administered any time between 0830 and 0930 using this policy. Does not apply to all drugs. A preoperative medication ordered to be given at 0730 should be administered at that hour because the time was planned in relation to the time that surgery is to begin.

7.      Signature of the prescribing provider.

prescribes use a unique username and password to access the system. As soon as you log in the system automatically records it.

Nurses are legally responsible for the drugs they administer. Therefore, it is important to question any drug order suspected to be in error. Always ask yourself why the patient is receiving the medication

.

Nurses have the right to refuse to administer any medication that, based on their knowledge and experience, may be harmful to the patient. Patient’s safety is a primary objective.

Medication Administration

●       Consist of medication orders

●       routes of administration

●        medication safety

●       Medication errors

●       Pharmacokinetics and Pharmacodynamics

●        Patient education on medication

●        Medication Administration Process

●        Medication reconciliation

Routes of medication are:

 Oral (PO): Most common and convenient route, but absorption can be affected by the GI tract.

Sublingual: Medication placed under the tongue for rapid absorption.

Inhalation: For medications delivered directly to the respiratory system (e.g., nebulizers).

Topical: Applied to skin or mucous membranes.

Intramuscular (IM): Injected into a muscle; faster absorption than subcutaneous.

 Intravenous (IV): Directly into the bloodstream, offering immediate effect.

Subcutaneous (Subcute): Injection into the fatty tissue under the skin.

 The order from fastest to slowest typically aligns with the following:

1.      Intravenous (IV) – The fastest because the medication is delivered directly into the bloodstream.

2.      Intramuscular (IM) – Faster than subcutaneous because of the rich blood supply in muscles.

3.      Subcutaneous (SubQ) – Slower than IM as the blood supply in subcutaneous tissue is less abundant.

4.      Oral (PO) – Slower due to the medication needing to be absorbed through the gastrointestinal tract and metabolized by the liver (first-pass effect).

5.      Topical/Transdermal – The slowest as the medication must penetrate the skin and is absorbed over time.

Medication Safety

Three checks and the Rights of medication

1.      When the nurse reaches for the unit dose package or container

2.      After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container. While preparing it for administration.

3.      Just before giving the unit dose medication to the patient, or when returning the multidose container. Check it again at the bedside before giving it to the patient.

High-Alert Medications: These have a high risk of causing significant harm if used incorrectly (e.g., anticoagulants, insulin, opioids). Extra precautions, like double-checking with another nurse, may be required.

Maintain a safety environment since it may contribute to accuracy in the preparation of drugs for administration.

When administering controlled substances make sure to:

➢     Name of the patient receiving the controlled substance

➢     Amount of the substance used

➢     Hour the controlled substance was given

➢     Name of the prescribing provider

➢     Name of the nurse who administered the substance

➢     Only physicians, nurse practitioners and physician assistants who are registered with the Department of Justice, Bureau of Narcotics, and Dangerous Drugs may prescribe opioids.

Rights of Medication- help to ensure accuracy when administering medication. They

themselves do not ensure medication safety

1.      Right medication

2.      Right patient

3.      Right dosage

4.      Right route

5.      Right time

6.      Right reason

7.      Right (appropriate) assessment date

8.      Right documentation

9.      Right response

10.    Right to education- ensuring that patients receive accurate and thorough information about the medication,

11.    Right to refuse- acknowledging that patients can and do refuse to take a medication.

Medication Errors-

Common causes: Similar drug names, unclear labels, incomplete patient information, or system errors (e.g., poor communication or unclear physician orders).

Preventions:

●       Follow the “six rights”

●       Be aware of “look-alike, sound-alike” medications

●       Use technology, such as barcoding to verify medication

●       Report errors immediately to ensure patient safety and to participate in system-wide improvements.

●       Pharmacokinetics and Pharmacodynamics

 Pharmacokinetics: How the body processes a drug, including:

●       Absorption: How the drug enters the bloodstream (depends on route).

●       Distribution: How the drug is carried through the body.

●       Metabolism: Mainly occurs in the liver, converting the drug into its active form.

●       Excretion: How the drug is eliminated, usually through kidneys.

 Pharmacodynamics: The drug’s effects on the body, including:

●       Therapeutic effects: The desired, beneficial effect of the drug.

●       Side effects: Unintended effects that are usually predictable (e.g., nausea).

●       Adverse effects: More serious, harmful effects (e.g., an allergic reaction)

Patient Education on medication:

●       Purpose of the medication.

●       How to take the medication (e.g., with food, on an empty stomach).

●       Potential side effects and when to report them.

●       Importance of adherence to the prescribed schedule.

●       Interactions: Educating the patient about potential interactions with other medications or foods (e.g., avoiding grapefruit juice with certain meds).

Medication Reconciliation

●       Is the process of comparing a patient’s current medication orders with all medications they are taking to avoid errors during transitions in care (e.g., admission, transfer, discharge).

●       Steps:

1.      Obtain a complete medication history.

2.      Compare the patient's current list of medications with new orders.

3.      Communicate any discrepancies to the healthcare provider.

●       Importance: Helps prevent omissions, duplications, dosing errors, or drug interactions.

Pediatric patients: Medications are often based on weight (mg/kg). Careful calculation and double-checking are essential.

Geriatric patients: Elderly patients may have altered metabolism and excretion, requiring adjusted doses. They are also more prone to polypharmacy and adverse drug reactions.

Medication Interaction

Medication interactions occur when one drug affects the activity of another drug when both are administered together. This can alter how drugs work in the body, potentially leading to either enhanced or reduced effects, or even harmful outcomes.

●       Additive Effect: When two drugs with similar actions are combined, their effects can add up. Example: Taking two medications that both lower blood pressure can cause excessive hypotension.

●       Synergistic Effect: When two drugs work together to produce a stronger effect than they would individually. Example: Antibiotics used in combination to treat severe infections.

●       Antagonistic Effect: When one drug reduces or blocks the effect of another. Example: A stimulant (like caffeine) can counteract the sedative effects of a medication.

●       Interference—one drug interferes with the metabolism of another; leads to the buildup of a medication (that cannot be metabolized) and can result in toxicity or an ADR.

●       Displacement—one drug binds to protein-binding sites and forces another drug to be displaced; results in the released drug becoming pharmacologically active and can lead to an increase in the effect of the unbound drug.

●       Dietary supplements, herbs and other natural remedies are another potential problem area for drug interactions.

Factors affecting drug interactions are:

●       Age: Older adults are more prone to drug interactions due to polypharmacy (taking multiple medications) and changes in metabolism.

●       Liver and Kidney Function: Impaired liver or kidney function can reduce the metabolism and excretion of drugs, increasing the risk of interactions.

●       Genetics: Genetic differences can influence how drugs are metabolized (pharmacogenetics). Some people may metabolize drugs more quickly or slowly, affecting drug levels in the body.

●       Timing: The timing of drug administration relative to food intake, other drugs, or even time of day can influence interactions. For example, some medications should be taken on an empty stomach to avoid interference with food absorption

●       Environment- the patient’s environment may influence that individual’s response to medication. Such as a noisy environment may not help if you just took a pain medication.

●       Culture- Religious restrictions and beliefs or cultural practices may affect the patient’s acceptance of, response to, and adherence to certain drug therapies. Look at box 30-1

●       Weight

Medication Reaction- there are seven types of reactions that can affect the human body.

Some of them are:

●       Adverse drug reactions- Harmful or unintended responses to a drug at normal dosages. ADRs can range from mild to severe and may require intervention.

-Ex: Gastrointestinal bleeding caused by nonsteroidal anti-inflammatory drugs (NSAIDs).

Categories of ADRs:

●          Mild: Rash, nausea, or headache.

●         Severe: Anaphylaxis, organ damage, or death.

Ex: would be “should the morphine cause a sudden drop in blood pressure”. Another example of an ADR is the development of an iatrogenic disorder caused unintentionally by drug therapy. Neutropenia caused by chemotherapy is another example.

➢     Side Effects- Predictable and often unavoidable secondary effects of a drug that are less severe than adverse effects. These are generally expected and may not require discontinuation of the drug.

Ex:  is drowsiness for antihistamines.

➢     Allergic Reactions- Immune system responses that occur when the body interprets the drug as a foreign substance and mounts a defense against it. These can range from mild (rashes) to severe (anaphylaxis).  Severe (Anaphylaxis): Life-threatening condition characterized by bronchospasm, edema of the throat, hypotension, and possible shock.

➢     Toxic Effects- Harmful effects caused by excessive drug levels in the body. These effects often occur when the drug accumulates in the body due to impaired metabolism or excretion, or when the dosage exceeds the therapeutic range.

Ex: Hepatotoxicity (liver damage) from excessive acetaminophen use.

➢     Idiosyncratic Effect- Unpredictable and unusual responses to a drug, often due to genetic differences in drug metabolism. These are rare and can occur the first time a drug is given.

 Ex: A patient develops an extreme reaction (e.g., agitation, confusion) to a sedative that usually causes drowsiness in most people.

➢     Drug tolerance- occurs when the body becomes accustomed to the effects of a particular drug over a period of time.

Factors affecting medication reaction

●       Age: Children and the elderly are more susceptible to drug reactions due to immature or diminished organ function (e.g., liver, kidneys).

●       Gender: Women may experience different or more intense reactions due to hormonal differences and variations in fat distribution.

●       Genetics: Genetic differences in drug metabolism can lead to variations in drug responses.

●       Pharmacogenetics: Study of how genetic variations affect individual responses to drugs.

●       Underlying Health Conditions: Patients with liver or kidney disease may have impaired drug metabolism or excretion, increasing the risk of toxicity.

Injection/Syringes

●       Types of injections

- Intradermal (ID) Injections- Administered into the dermis, just below the skin surface. Used for allergy testing, tuberculosis (TB) screening. Administer in a 5-to-15-degree angle. Usually uses a 25 to 27 gauge.

- Subcutaneous (SubQ) injections- Administered into the adipose tissue layer just below the dermis. Common use is by insulin, heparin, and some vaccines. Administer in a 45 to 90 degrees.

- Intramuscular (IM) injections- Administered into the muscle tissue. Common uses are on vaccines, antibiotics, and hormonal medications. Common sites of injections would be the deltoid, ventrogluteal, and vastus lateralis. 

- Intravenous (IV) injection- Administered directly into the vein. It is a rapid administration of medications, fluids, or blood products.

●       Syringe

- A syringe component

  - Barrel: The part that holds the medication. It is calibrated for accurate measurement.

 -Plunger: Used to push the medication through the needle.

   -Tip: The end where the needle is attached, usually a Luer-lock (twist-on) or non-Luer-lock (slip-on) tip.

●       Types of Syringes

-Standard syringe

- Insulin syringe

- Tuberculin syringe

●       Needles

-Components

Hub: Attaches the needle to the syringe.

Shaft: The long, slender part that penetrates the tissue.

Bevel: The angled opening at the tip of the needle, which should always face up during injection.

Common Gauge

                  11.21. gauge: for thicker medications, such as certain antibiotics.

                22-27 gauge: for standard IM or SubQ injections.

                                 25-27 gauge: for thinner medications, such as vaccines or insulin.

●       Injection Techniques

Z-track Method- Recommended for IM injections to prevent medication from leaking into subcutaneous tissue, particularly with irritating or staining medications (e.g., iron injections). This technique involves pulling the skin laterally before inserting the needle, then releasing it after withdrawal to “trap” the medication.

●       Needle Safety and Disposal

Needlestick Prevention:

●        Never recap needles after injections to avoid accidental needle sticks.

●        Use safety-engineered needles and syringes with protective covers.

Disposal:

●        Dispose of all needles and syringes immediately in designated sharps containers

●       Never overfill sharps containers, and follow institutional policies for safe handling