Test 1 Medication Administration PDF

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NR 462 Medication Administration Taylor CH 28 Objectives  Explore the process of safe medication administration, routes of medication administration, and the role of the nursing in monitoring for efficacy and deleterious medication reactions  Discuss medications, side effects, compatibility, relationships, and adverse reactions  Describe nursing assessment before, during, and after med administration  Administer meds using “3 checks” and 6 rights  Describe steps if a med error occurs History of Medication Safety (Hillin, 2010)  In 1999, IOM “To Err is Human” published and reported that 44,000 to 98,000 hospital patients die each year due to medical errors  20% of hospitalized patients will experience a preventable and potentially serious medication error.  Estimated loss of 7000 lives per year o Emergency Department is a high risk area  Medication errors are among the most common medical errors, harming at least 1.5 million people every year, says a new report from the Institute of Medicine of the National Academies. The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says. http://www8.nationalacademies.org/onpinews/newsitem.aspx?recordid=11623

Nurses Role You are the last line of defense  Nurses are legally responsible for medications they administer, INCLUDING knowledge of drug actions and side effects and the questioning of orders they believe are incorrect.  Monitor patient and always Document Patient Rights  Be informed about a medication  Right to refuse…regardless of consequences (Nurse also has right to refuse to give medication if uncomfortable with  Consent prior to receiving investigational drugs  Medication Reconciliation…review of medication history  Receive drugs safely and not unnecessarily Resources for understanding and researching Medications

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PDR- Prescribers’ Digital Reference Other Medication Texts Pharmacist Package inserts Computer software...Micromedex

ALL Medication Orders MUST HAVE 7 Essential Elements  Patient Name (ensures Right Client)  Name of the drug to be administered (ensures Right Medication)  Dosage of the drug (ensures Right Dose)  Route of administration (IV, IM, PO, etc.) (ensures Right Route)  Frequency of administration of the drug (ensures Right Time)  Date and time the order was written  Signature of MD or LIP Question When administering medication, the nurse ensures client safety by following the rights of medication administration. Identify the “rights of medication administration.” Select all that apply  Right room  Right client  Right dose  Right medication  Right time  Right route  Right documentation Nursing Process & Medication Administration  Assessment o History- provides indications and contraindications for drug therapy o Medication reconciliation o Food or Drug allergies o Diet history o Pregnancy and lactation status o Perceptual or coordination problems o Current condition o Client’s attitudes o Client knowledge & understanding of drug therapy determines learning needs  Need to understand why they are taking medications (what it is indicated for in that patient), how to take them, etc  Prior to Administration: o HAND HYGIENE o Compare the original MD/Provider Order with the MAR or EMR  Clarify any differences  MAR=Medication administration record  EMR=Electronic Medical Record o Diet and fluid orders o Laboratory values o ALLERGIES  Physical Assessment o Ability to swallow

o GI motility o Adequate muscle mass o Adequate venous access o Vital signs, blood sugar, etc. o Body system assessment  Planning: Educate o Explain the mechanism of action and side effects. Be realistic about what you are telling the patient. Important to know how much information is appropriate for the individual Question: After the discharge of a client from a unit, the housekeeper brings a blue pill to the nurse. The pill was found in the sheets when the linens were removed from the client’s bed. The nurse reviews the client’s medication administration record, which shows that the client received this medication at 0800. What would be the nurse’s priority action? o Complete an incident form and notify the physician o Don’t do anything because the client was discharged o Tell the housekeeper not to worry if this happens in the future o Advise the housekeeper to throw the pill in the garbage Nursing Considerations: Medication Administration Safety Three Checks of the Medication 1. Compare MAR to Medication Order: After reading the MAR, read the medication label whenever you select the container or unit dose package (ex. comparing MAR to computer) 2. Compare MAR to Medication: Read it after you take it from the drawer and compare to the MAR before pouring (do not open single dose medication until right before it is given) 3. Right before you give it to the medication to the patient (TWO identifiers) 4. Document the medication administration AFTER administration. Medication Systems: Stock Supply  Bulk quantity  Central location  Not client-specific Unit Dose  Individually packaged  Client-specific drawers  24-hour supply

Automated Dispenser  Password-accessible locked cart  Computerized tracking  Can combine stock and unit doses Self-Administration  Individual containers  Kept at client’s bedside Pyxsis/Accudose

Six Rights 1. Right drug/medication 2. Right patient 3. Right dose 4. Right route 5. Right time 6. Right documentation (Taylor p. 795)

May be others  Right reason  Right assessment  Right education  Right response

Right Patient o Two Patient Identifiers- have patient tell you (a confused patient may verify wrong info)

o Name and Date of birth  Common Names o Record number on ID band o What do you compare your 2 identifiers against? Check wristband, check MAR Right Route (Table 28.2) o Double check your route: o Oral (PO)- swallowing a drug, 30-90 min  Enteral- administering drug through an enteral tube  Sublingual- placing drug under tongue (not swallowing) 3-5 min  Buccal- placing drug between cheek and gum (not swallowing)  Drugs swallowed orally usually take the longest to be absorbed, and also have more prolonged effects.  Know that NPO= NOTHING BY MOUTH o Parenteral- injecting drug into…  Subcutaneous injection (SQ)- subcutaneous tissue, 15-30 min  Intramuscular injection (IM)- muscle tissue 10-20 min  Intradermal injection- corium (under epidermis)  Intravenous injection (IV)- vein  Intra-arterial injection- artery 30-60 sec  Intracardial injection- heart  Intraperitoneal injection- peritoneal cavity  Intraspinal injection- spinal canal  Intraosseous injection- bone 30-60 sec  Injected medications are usually absorbed more rapidly than oral medications.  Drugs administered intravenously are placed directly into the bloodstream, thus technically are not absorbed and take effect quickly o Topical route- Applying drug onto skin or mucous membrane  Vaginal administration  Rectal administration 5-30 min  Inunction- Rubbing drug into skin  Instillation- Placing drug into direct contact with mucous membrane  Irrigation- Flushing mucous membrane with drug in solution  Skin application- Applying transdermal patch o Pulmonary- respiratory inhalations 2-3 min o Many drugs, such as eye drops, eardrops, nasal sprays, respiratory inhalations, and transdermal drugs, have little absorption; the action of these drugs is mostly local, at the site of administration

Right Time o When time meds are due is set by facility

o Window: 30 min-1 hour before & after o Should the medication be taken with meals or empty stomach? o What if the person is NPO for a procedure? o Some abbreviations o PRN= as needed o STAT= single order, carry out immediately o AC= before meals o PC= after meals o On Call? = prior to a procedure? o “Now”= w/in 60 minutes? Right Documentation  The name of the medication, dosage, route of administration, time given, and name of the person administering the medication are noted in the record. o Record the site used for an injection. o Record other relevant information (BP for BP drugs, etc)  Omitted/withheld Drugs o Drugs may be omitted intentionally for the following reasons:  The problem for which the medication is intended no longer exists. For example, a laxative has been ordered for a patient. The patient has had a bowel movement and no longer needs the laxative. The laxative is then omitted.  The patient is to have a diagnostic test and is required to fast before the test. Oral drugs may be omitted, or their administration may be delayed, depending on the primary care provider’s orders.  The patient is suspected of having an allergy to the medication. Any suspected allergy should be reported to the primary care provider.  Refused Drugs o Patients have a right to refuse medication o Describe the refusal to take prescribed drugs and the manner in which the situation was managed in the patient’s record and report the refusal according to facility policy. Basic Medication Safety o Prepare medication for only one client at a time o Compare order with medication available o Calculate drug dose o Make sure you are not distracted while dispensing medications (phone, conversation…) Safety! Safety! Safety! o Compare prepared medication to MAR o Check medications at least 3 times before administering o Take directly to patient o 2 patient identifiers o Complete required assessment o Explain purpose of medication Question: A nurse is caring for a client who is vomiting. The physician has ordered oral dimenhydrinate. What is the most appropriate action by the nurse to help the client?  Administer the medication intravenously due to the vomiting

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Notify the physician of the vomiting, and obtain a new medication order (probably new route- CANNOT change route without a new order) Administer the oral medication, and monitor the client’s emesis Wait for the vomiting to cease, and then administer the oral medication

Oxygen Administration A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease.  Ist line when appropriate  Low flow- smallest amount of oxygen  Flow Rate 1-6 Liters/minute  Placed in Nares Simple mask allows the administration of higher levels of oxygen than a cannula.  Flow Rate 5-10 Liters/min  Delivers 40-60%  When O2 sats dropping with NC use or mouth breather Venturi Mask  Flow rates 4-12 Liters  Provides 30-80%  A more carefully delivered flow rate  Gold standard for COPD; anytime you need exact percentage. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.  Flow Rates 6-15 liters  High flow oxygen  Provides 60-100%  Example: Chest pain Oxymizer  Facilitates conservation through the use of a reservoir that stores oxygen during exhalation for delivery during inhalation  Forms- mustache or pendent  Flow rate should begin at 6L oxygen Face tent is used for clients with facial trauma and burns. Oxygen Safety Make sure you have an order, O2 is considered a drug (can be given w/out order though?)  Understand your delivery devices  Assess flow meter settings for accuracy  Assess breath sounds pre and post therapy  Assess pulse Ox  Assess skin integrity  Fall risk

Oral Medication Administration o HAND HYGIENE FIRST o Always verify an order when administering- 5 tablets…, 5 milliliters in a syringe… o Do not touch pills when dispensing o Use bottle lid to dispense from bottle to cup o Tablets that must be given in partial dosage must only be broken along score lines (use gloves and pill cutter as needed)  Unused portions are discarded properly. o Liquids at eye level o Fill till bottom of meniscus is at desired mark in graduated cup o Can also use syringe if appropriate o Keep single unit dose in wrapper until at bedside ready to administer o Controlled substances, Narcotics- must account for o Assist patient to sitting position o Offer client medication in cup or in hand (their preference and offer water o Stay with client until all medications are swallowed – DO NOT leave at the bedside o If client feels like the medication is stuck in their throat, offer crackers or water to help move pill if crackers are allowed o If soon after taking medication the patient vomits- make sure patient is in a safe position, must inspect vomit for the medication. If medication is visible, provider may recommend readministering same dose amount. Buccal and Sublingual o Placed in the mouth, but NOT SWALLOWED o Buccal are held in the cheek o Sublingual (SL) is under the tongue Transdermal Medications o Protect yourself…wear gloves o Assess patient’s skin where patch is to be placed, looking for any signs of irritation or breakdown. Site should be clean, dry, and free of hair. Rotate application sites. o Remove any old transdermal patches from the patient’s skin. Fold patch in half with adhesive sides sticking together and discard according to facility policy. o Gently wash the area where the old patch was with soap and water. o Remove the patch from its protective covering. o Remove the covering on the patch without touching the medication surface. Apply the patch to the patient’s skin. Use the palm of your hand to press firmly for about 10 seconds. Do not massage. o Do not cut or modify a patch o Depending on facility policy, initial and write the date and time of administration on a piece of medical tape. Apply the tape to the patient’s skin in close proximity to the patch. o Do not write directly on the medication patch. Ophthalmic Medications (Taylor Guidelines for Nursing Care 28-3) o Ensure the package states “for ophthalmic use only” o OD ………………… oculus dexter (the right eye) o OS ………………… oculus sinister (the left eye) o OU ………………… oculus uterque (both eyes) o Care to not cross contaminate…do not touch the eye or conjunctiva o Hold the dropper close to the eye but avoid touching the eyelids or lashes.

o Touching the eye, eyelids, or lashes can contaminate the medication in the bottle; startle the patient, causing blinking; or injure the eye. o Allow drops to fall in the lower conjunctival sac.  Do not allow drops to fall onto the cornea, may cause injury or discomfort o Release the lower lid after the eye drops are instilled. Have patient close the eyes gently. o Apply gentle pressure with your gloved finger over the inner canthus to prevent the eye drops from flowing into the tear duct. Otic/Ear Drops (Taylor Guidelines for Nursing Care 28-4) o Purpose- used to soften wax, relieve pain, local anesthesia, treat infection, destroy organisms o Ear drops or irrigating solutions must be the proper temperature o Sterile technique is used if tympanic membrane is damaged o Know proper position of patient o Have patient lie on side or hold head tilted to side o Straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back in an adult, straight back for a child older than 3, and down and back in an infant or a child under age 3 years o Do not touch ear with dropper o Allow drops to fall on the side of the canal. Avoid instilling in the middle of the canal, to avoid instilling directly onto the tympanic membrane. o Gently press on the tragus a few times to help move the medication from the canal toward the tympanic membrane. o If ordered, loosely insert a cotton ball to prevent medication from leaking out. o Wait 5 minutes before instilling drops in the second ear, if ordered. Nasal, Nebulizer, Meter-Dose Inhalers (MDI) (Taylor Guidelines for Nursing Care 28-5,8) o Local effects o Alveolocapillary network quickly absorbs medication o Coordinated movements sometimes required o Read directions carefully and have patient return demonstrate administration Rectal/Vaginal Administration (Taylor Guidelines for Nursing Care 28-6,7) o Suppositories; foams; jellies; creams o Body temperature liquefies and distributes medication o Standard precautions o Privacy if client self-administers o Quick absorption time o Avoid rectal for patients with recent rectal or prostate surgery, low platelet or WBC, cardiac arrhythmias o Rectal are given with patient in left side sims position Enteral Medications o Medications instilled through a feeding tube o Some medication should not be crushed- “Enteric Coated” o Flush between meds. Tube can become occluded with medications Evaluation o Nurse must monitor the effect and effectiveness of medications at all times

o Nurse must know therapeutic actions & side effects and be alert to changes in health status as a result of drug therapy Questioning a med order? o Any order that is ambiguous, unusual or contraindicated by the client’s condition. o Contact prescriber – discuss your rationale for believing medication is inappropriate o Use SBAR: Situation, Background, Assessment, Recommendation and state “Clarify the order..” o Document – When the provider was notified, What was conveyed to the provider, How the provider responded o Can’t reach the provider? Document all attempts and the reason for withholding the medication and notify immediate supervisor o You are responsible for your own actions – question any order you consider incorrect or inaccurate o Check the client’s ID band against the MAR before administering any medication – 2 patient identifiers o Assess whether a client can swallow before administering oral medications o Do NOT give medications prepared by anyone other than yourself What if I Commit a Medication Error? o Immediately assess the patient’s status. o Report findings to the primary care provider. o Notify the nurse manager of your unit and report the event surrounding the event. Check with your institution for agency-specific policy regarding incident reporting. The nurse is preparing medications and is notified that a health care provider is on the phone. What is the nurse’s appropriate response? Preparing medications requires uninterrupted concentration. The nurse will ask that a message be taken and contact the provider after medication preparation is complete. The nurse should not be on the phone and attempt to complete medication preparation, nor should the nurse ask another nurse to prepare medications for his or her clients....