Chapter 35 Medication Administration PDF

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Summary

Safe nursing practice includes knowledge about medication actions; side effects; interactions with foods, herbs, and other medications; associated assessment and evaluation; ethical considerations; and legal aspects of medication therapy. Medication management requires the collaborative efforts of m...

Description

! • Safe nursing practice includes knowledge about medication actions; side effects; interactions with foods, herbs, and other medications; associated assessment and evaluation; ethical considerations; and legal aspects of medication therapy.! • Medication management requires the collaborative efforts of many health care team members, such as the prescribing primary care provider (PCP), pharmacist, respiratory therapist, and dietician.! • Continuing education of nurses is needed to ensure that standards of practice are met, new or unfamiliar medications are administered properly, and medication administration technology is used correctly.!

Medications and Regulations • Drugs and medications

• chemical name - elements of the meds molecular structure ! • official name - assigned by the U.S. Adopted Names Council, usually the generic name ! • generic name - not capitalized and often contains a prefix or suffix that helps identify the drug class! • trade (brand) name - registered name assigned by the drug manufacturer • Medication standards and regulations

‣ Help public safety by identifying medication properties that show an appropriate range of quality and purity!

testing before being released to the public. • Controlled substances

dispensing requirements.!

clinical staff members must witness the appropriate disposal of the substance and document the wasting of the drug. • State and local medication regulations

administering any medication, particularly controlled substances.

Principles and Drug Actions • Pharmacokinetics - the study of how a medication enters the body, moves through the body, and ultimately leaves the body!

• Several factors affect absorption: route of administration, ability of the drug to dissolve or become soluble, blood flow to the administration site, body surface area, and patient age.! • Intravenous is quickest, then intramuscularly, subcutaneously, and orally administered medications ‣ Distribution - the process of delivering the med to tissues and organs and ultimately to the specific site of action! • affected by the chemical properties of the drug, the effectiveness of the cardiac system, the ability to pass through tissue and organ membranes, and the extent to which the drug binds to proteins or accumulates in fatty tissue ‣ Metabolism - process by which a drug is altered to a less active form to prepare for excretion! • The products of this process are called metabolites. ‣ Excretion - removes the less active drug or its metabolites! • exit the body through the kidneys, but some may be excreted in feces, breath, saliva, sweat, and breast milk • Pharmacodynamics - process in which a medication interacts with the body's cells to produce a biologic response!

excretion.! ‣ organs that can be damaged from drug toxicity include the kidneys (nephrotoxicity), liver (hepatotoxicity), organs of hearing (ototoxicity), and heart (cardiotoxicity)!

‣ Severe - anaphylactic reaction

‣ If medications that are not compatible are prescribed, they must be administered separately with appropriate safety measures, such as flushing the IV tubing between medications.

Nonprescription and Prescription Medications • Nonprescription medications

allergic reactions, 3) potential interactions with other medications and herbs, 4) warnings, 5) directions and dosage, and 6) features (such as safety caps). ‣ Vitamins • The body uses vitamins for the biologic processes of growth, digestion, and nerve function. ! • Water-soluble vitamins are excreted by the body through the kidneys. (B complex and C vitamins)! • Fat-soluble vitamins are stored by the body for use as needed; however, excess can build up in the liver, so they must be used with caution. (A, D, E, and K vitamins) ‣ Alternative therapies • Herbal medications come from plants or a plant part and are found in many foods.! • The FDA regulates herbs and dietary supplements through the Dietary Supplement Health and Education Act (DSHEA). • Prescription medications

prescription ‣ Prescribing medications is limited to physicians, dentists, specially qualified nurse practitioners or other advanced practice nurses, and physician assistants! ‣ A medical order from any health care setting must have several components to be a legally valid medication prescription:! • Patient's name! • Date and time the order is written! • Name of drug to be administered! • Dosage of the drug! • Route of drug administration! • Frequency of drug administration! • Signature of the person writing the order!

care. The nurse values technologies that support error prevention in medication administration.

Forms of Medication and Routes of Administration

• Forms of medication —> • Routes of medication administration - Medication preparations are not interchangeable for alternate routes. !

injection or infusion), topical (on skin or mucous membranes), by inhalation, and through a medical tube. ‣ Oral administration (PO - by mouth)! • Safest, most convenient, least expensive ! • Slower onset! • Can often be administered through nasogastric, gastric, intestinal, and jejunal tubes when they are ordered to be given via that route ‣ Topical medications • Applied to a specific skin surface or mucous membrane of a body cavity! • Liquids and ointments can be directly applied to the eyes.! • Suppositories can be inserted into the rectum or vagina.! • Fluids can be instilled into a body cavity such as the ear, nose, bladder, or rectum. ! • A spray can be applied to the throat. ! • Lotions and ointments can be applied to any skin surface.! • A transdermal patch is a topical preparation designed to deliver medication slowly for systemic effects (nicotine for smoking cessation, pain medication such as fentanyl, nitroglycerin for angina).!

other medications with special coatings cannot be administered through a tube. Contact the PCP to safely change the prescribed medication to an alternate administration route or formulation, if needed. ‣ Inhaled medications • Medications for inhalation are taken into the body through the respiratory tract. !

• Means of delivery include small amounts of fluids, metered-dose inhalers (MDIs), turbo-inhalers, and nebulizers ‣ Parenteral medications • Administered by injection into tissue, muscle, or a vein ! • Faster ! • Aseptic technique is used! • There are four major sites of injection:!

below the skin!

and type of medication!

‣ Parenteral medication preparation • There are other parenteral routes (e.g., epidural, intrathecal, intraosseous, intraperitoneal, intraarterial) that only advance practice nurses in specialty areas or physicians can use to administer medication.! • Needleless delivery systems significantly decrease needlestick injuries and exposure to blood-borne pathogens.

Safe Medication Administration

• Accountability is based on facility policies and procedures and on the American Nurses Association's Nursing: Scope and Standards of Practice (2015) for medication protocols and legal expectations. ! • Before administering a medication, the nurse should check the patient's MAR or the primary care provider's prescription, review diet and fluid orders, review relevant laboratory values, and perform a brief physical assessment.! • Nurses are legally accountable for medications they administer and for recognizing side effects and adverse reactions. Questions regarding the purpose, dose, route, time, abbreviations, relation to laboratory values, potential interactions, allergies, or patient response must be resolved with the PCP or pharmacist before the nurse administers the medication. The nurse has the right and responsibility to refuse to administer a medication if he or she feels that the prescribed medication endangers the safety of the patient, but the PCP must be notified of the refusal to administer the medication.

administration.! ‣ The nurse should clarify orders with the prescriber that are difficult to read, do not contain all of the critical information needed for safe administration, or contain prohibited or unfamiliar abbreviations.

techniques.! ‣ The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. These events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”! ‣ The nurse is the patient's last line of defense against mistakes. ! ‣ Many facilities have a No Interruption Zone policy for medication administration.! ‣ If a medication error occurs, the nurse's priorities are to determine the effect on the patient and intervene to offset any adverse effects of the error.! ‣ Actions include immediate and ongoing assessment, notification of the prescribing PCP, initiation of interventions as prescribed to offset any adverse effects, and documentation related to the event. Error reporting is an essential component of patient safety and should be completed as soon as the patient is assessed and stable.! ‣ Creating a culture of safety, the nurse describes factors such as open communication strategies and organizational error reporting systems. The nurse uses organizational error reporting systems for any medication error.

medication administration factors, basic safety design principles, and commonly used unsafe practices (such as dangerous abbreviations).

medication calculations: metric, apothecary, and household. ! ‣ When noting a metric dose, always place a zero in front of the decimal point, and never have a trailing zero. For example, doses are identified as 0.5 mL instead of .5 mL and as 5 mL instead of 5.0 mL. • Calculation methods

quantity of medication and the desired (prescribed) quantity.

right documentation.! ‣ The first safety check consists of confirming that the label of the medication matches the MAR, performing any necessary dosage calculations, reviewing patient allergies, and verifying the expiration date of the medication. ! ‣ The second safety check consists of preparing the medication and again checking the medication label against the MAR. ! ‣ The safety third check is a recheck of the medication label a final time against the MAR before opening the package at the bedside or a recheck of the label on the medication before returning the medication to its storage place. • High risk situations for med administration • Patient rights

!

Assessment • Information about a patient's allergies to drugs and food and the patient's pregnancy or breastfeeding status is especially critical.! • The initial assessment produces baseline data, and medication-specific assessment is part of ongoing care by the nurse.! • Important data to be collected are:!

the medication administration record (MAR). The pharmacy and dietary departments are notified about allergies, and an allergy band is placed on the patient's wrist. • Common laboratory tests monitored to assess medication responses include electrolytes, serum glucose, complete blood count (CBC), white blood cell (WBC) count, bleeding time, blood urea nitrogen (BUN), creatinine, and serum levels of specific meds.!

Implementation and Evaluation The National Institute for Occupational Safety and Health (NIOSH) has identified multiple drugs as hazardous to nurses who administer or prepare them. Most of the hazardous drugs require special handling by health care workers to avoid exposure to potentially serious health outcomes (such as skin rashes, infertility, spontaneous abortion, and cancer). • Medication administration

mucosa from irritating medications. Crushing a sustained-release medication allows absorption to occur all at once rather than the desired absorption over time.! ‣ Never return unused medication to a multidose container. Never administer medication that is not labeled.

‣ Nitroglycerin for chest pain! ‣ Buccal medication should not be chewed, swallowed, or taken with liquids.

absorption. (Suppository)! ‣ Gauze dressing may be applied over the medication to prevent removal of the medication by clothing. ! ‣ Gloves and applicators are used to avoid absorption through the nurse's skin during placement of topical medications.

‣ Placement sites are rotated to avoid skin irritation. (Estrogen, nitroglycerin, fentanyl)

infections, or disorders, such as glaucoma.

‣ The internal ear is very sensitive to temperature changes, and it is important to use eardrops at room temperature to prevent nausea, pain, and dizziness.! ‣ If the tympanic membrane has been damaged, all procedures are performed with sterile technique to prevent infection.! ‣ Medication should not be forced into the ear canal because forcing may rupture the tympanic membrane.

‣ The nose is a clean, not sterile, cavity, but the nurse uses medical asepsis when administering nasal preparations because of the connection of the nose to the sinuses.! ‣ They may have systemic effects such as increased heart rate and a rebound effect that increases congestion.

‣ Each time the device is pressed, a specific dose is released. ! ‣ Medication absorption is very rapid.! ‣ Common uses for inhaled medications are to induce anesthesia during surgery and to treat respiratory disorders, such as asthma or chronic lung disease.! ‣ Assessment before and after administration of inhaled medications includes assessment of breathing status, breath sounds, respiratory rate, and use of accessory muscles.! ‣ Rinsing the mouth and oral care should be performed by the patient receiving steroids by inhalation. This prevents irritation to the oral mucosa and tongue and prevents oral fungal infections.

‣ They are used for infection, itching, antibacterial preparation before surgery, contraception, or induction of labor. ! • Vaginal suppositories are typically refrigerated until use because they melt at body temperature.! • Tampons should not be used after medication instillation.

antipyretic effect). ! ‣ Rectal suppositories are often stored in the refrigerator.! ‣ Clean, disposable gloves are used when administering suppositories.! ‣ The unwrapped suppository is placed above the internal anal sphincter and against the mucous membrane for proper retention and absorption. ! • For a laxative effect, the suppository needs to remain in the rectal vault for 15 to 45 minutes or until the patient feels the urge to defecate.! ‣ Liquid medications are instilled in the rectum using an enema solution. ! • An enema solution can be used to treat patients with high potassium levels or to rid the bowel of stool before a procedure. (Small 100mL - retain 5min; Large 1000mL - retain as long as possible)

‣ Smaller gauge = larger needle (e.g., 18-gauge is larger than 25-gauge) ! ‣ Standard precautions and sterile technique are followed when using the parenteral route because the skin barrier is broken. ! • SQ: 1 mL syringe & 3/8-5/8 in, 25-31 gauge needle! • IM: 3 mL syringe & 1-3 in, 19-25 gauge needle! ‣ The nurse demonstrates safety by the effective use of strategies to reduce the risk of harm to self or others by immediately activating the safety mechanism on a needle after administering an injection.! ‣ After use, a needle should not be recapped (placing the protective cap back over the needle). Most needlestick injuries occur during recapping. Needlesticks expose health care workers to blood-borne pathogens, such as human immunodeficiency virus (HIV) and hepatitis B and C viruses.! ‣ The needle safety mechanism is activated immediately after the syringe and needle are used for medication administration. This step is critical in preventing a needlestick injury • Preparing parenteral medications

• Ampules range in size from 1 mL to 10 mL (or larger), but all have a constricted neck area that is snapped off to allow access to the medication. ! ‣ A vial is a glass or plastic container holding one or more doses of a solution or medication.

‣ Incompatible Meds: Cloudy or forms a precipitate! ‣ An Act-O-Vial system (i.e., dual-compartment vial) is another approach for administering powdered medication. ! • In this system, the medication powder (e.g., methylprednisolone sodium succinate) and diluent are in two compartments of a single vial, separated by a rubber stopper. To prepare the Act-O-Vial for administration, the nurse depresses the stopper to combine the diluent and medication, gently mixes the solution, and withdraws the prescribed dose.

‣ Care is taken to lock the cartridge into the injection holder to stabilize it during administration.! • Before injection, the cartridge is cleared of air and excess medication because products may be overfilled, risking overdose, or the dose ordered may be smaller than the amount of medication contained in the cartridge. ! • After administration, the cartridge is removed from the holder and placed in the appropriate disposal container. ! ‣ Examples of prefilled cartridge holders include Tubex and Carpuject appliances.! ‣ The transfer of medication from a prefilled cartridge to a different syringe is done if a needleless system is in place or a safety needle is available for use instead of the needle supplied with the cartridge.! ‣ A single dose of medication is in a syringe with a needle attached. ! • Excess air or medication may need to be expelled from the syringe; however, some prefilled medication syringes, such as enoxaparin, contain air that should not be removed before administration.

within the guidelines for administration into a parenteral site. ! ‣ Incompatible medications may become cloudy or form a precipitate when mixed. ! ‣ Aseptic technique is used

• Administering parenteral medications ‣ Intradermal administration • Intradermal injections are given into the dermis, the layer of tissue just below the skin surface.! • The intradermal route is often used to administer local anesthetics, to test for allergies, and to test for tuberculosis exposure. (1 mL syringe with 25-27 gauge,¼ to 5/8 in needle) ! • No pressure or massage ‣ Subcutaneous administration • Subcutaneous tissue is the layer of fat located below the dermis and above muscle tissue.! • Insulin and heparin are medications commonly administered by the subcutaneous route. ! • Absorption is slow, with a sustained effect.! • Common subcutaneous sites include the abdomen, lateral aspects of the upper arm and thigh, scapular area of the back, and upper ventrodorsal gluteal area.! • Some types of insulin are supplied in special multidose devices called insulin pens. !

does not have to be drawn up. ‣ Intramuscular administration • Because there are more blood vessels in muscles than in subcutaneous tissue, IM injections are absorbed rapidly if the patient has adequate circulation.! • When preparing to administer an IM injection, the nurse considers the volume of fluid to be injected, medication being administered, injection technique, site selection, and syringe and needle selection. Other factors include the patient's age and condition.! • The three common IM injection sites are ventrogluteal, vastus lateralis, and deltoid.! • Failure to find the correct injection site by using anatomic landmarks before injecting medication can result in tissue, bone, or nerve damage.! • Intramuscular injections of medications that discolor tissue (e.g., iron) or are irritating to tissue (e.g., hydroxyzine) are administered by the Z-track method. !

‣ Intravenous administration • The IV route is used when a rapid drug effect is desired or when the prescribed medication is irritating to tissues. (Remove air from tubing; and flush p...