34.1 - Medication Administration

Question 1

Canadian drug legislation

Answer 1

The Health Protection Branch of the federal government is responsible for the administration of the Food and Drug Act and the Controlled Drugs and Substances Act. New drugs need to apply to the Health Protection Branch for approval

Question 2

Guidelines for Safe Narcotic Administration and Control

Answer 2

• Must be kept double locked
• Narcotics are counted and a record is kept separate from the patient administration record
• Narcotics are counted every time they are accessed and counted by 2 nurses at shift change – one coming on and one going off shift
• Use a special inventory record each time a narcotic is dispensed
• Report discrepancies in narcotic counts immediately

Question 3

Pharmacokinetics 4 fundamental processes:

Answer 3

Absorption, distribution, metabolism and excretion

Question 4

Factors that influence absorption:

Answer 4

• Route of administration (IV fast, topical slow)
• Ability of the medication to dissolve
• Blood flow to site of administration (increase temp = increased blood flow = increase rate of absorption)
• Surface area
• Lipid solubility of medication

Question 5

Fastest absorption

Answer 5

1) IV bypasses absorption, it’s automatically in the blood
2) Inhalation
3) Injection into muscle
4) Subcutaneous is slower
5) Topical from skins surface is slowest

Question 6

where are acid/base absorbed?

Answer 6

Basic meds are absorbed in small intestine (enteric coated)
Acidic meds are absorbed in stomach through gastric lining

buffered just means that the drug contains ions to decrease acidity and slow absorption of acidic drugs.

Question 7

Do not crush or chew or open drugs that

Answer 7

1) extended release (high dose of medication intended to be released slowly over time) as the entire dose may be released at once,
2) enteric coated (have a hard waxy coating designed to be released in the small intestine, or medications with oral effects such as extremely bitter taste, stain teeth or irritate the mucosa

Question 8

Distribution depends on

Answer 8

Circulation
Membrane permeability
Protein binding

Question 9

drugs that can cross placenta

Answer 9

(alcohol, cocaine, caffeine, some prescription meds),

Question 10

Protein binding

Answer 10

Most medications bind to proteins to some extent and the amount they bind affects the distribution. Medications bound to albumin cannot exert pharmacological activity. The unbound, or free, medication is the active form of the medication. People with a decrease in albumin, such as older people or people with decreased liver function, will have a higher amount of unbound medication. This means they may be at risk for an increase in medication activity or toxicity, or both.
Warfarin 99% bound, leaves 1% of the drug that is free or unbound
Gentamicin is 10% bound or 90% free

Ration of bound drug to unbound drug is constant. As the free drug exits the blood, an equal proportion becomes unbound to replace the free drug that exited the system. This can create a reservoir of unused drug because the drug is prevented from leaving the blood stream. It can slow the rate of disappearance from the plasma and it limits the rate of accumulation of drug in the tissue.

Question 11

Medications are excreted via

Answer 11

Kidneys – primary location of excretion, as urine
Liver – broken down and secreted in bile
Bowel– excreted in feces
Lungs – most drugs excreted from lungs unmetabolised
Exocrine glands – salivia, sweat, breast milk

Question 12

Mild Allergic Reactions

Answer 12

• Urticaria raised, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and pale centre
• Rash Small, raised vesicles that are usually reddened; often distributed over entire body
• Pruritus Itching of skin; accompanies most rashes
• Rhinitis Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge

Question 13

Factors that affect med Blood concentration

Answer 13

The drugs half life
The size of the dose
Frequency
Pharmacokinetic processes
Route

Question 14

Factors that Influence Drug Action

Answer 14

Body weight and composition
Genetics
Physiological factors – hormones, age and disease
Environmental condition – cold causes vasoconstriction
Psychological

Question 15

4 sites of injection:

Answer 15

1) Intradermal (ID): Injection into the dermis just under the epidermis into dermis of skin. More blood vessels than sc. Allergy testing, Mantoux. 0.1-0.2mls. Sites: upper back, scapula, high upper chest, inner forearm
> Subcutaneous and intradermal. Difference between these is depth.

2) Subcutaneous (subcu): Injection into tissues just below the dermis into fat tissue: insulin, heparin,
3) Intramuscular (IM): Injection into a muscle
4) Intravenous (IV): Injection into a vein

Question 16

Medications can also be administered into body cavities - 8

Answer 16

1) Epidural – administration into the epidural space via catheter by an anaesthesiologist (analgesics)
2) Intrathecal – medications administered with catheter into subarachnoid or ventricles in the brain injection into spinal cavity (goes to cerebral spinal fluid) anesthesia
3) Intraosseous – meds directly into the bone marrow (used in children or emergencies)
4) Intraperitoneal – meds administered into the peritoneal cavity
5) Intrapleural – injection or chest tube to administer directly to pleural space
6) Intra-arterial – medications administered directly into arteries, usually through indwelling catheters
7) intracardia (meds into cardiac tissue)
8) intra-articular where meds are injected into a joint

Question 17

in any given year, an estimated ______ people die from medical errors that occur in hospitals

Answer 17

, in any given year, an estimated 98 000 people die from medical errors that occur in hospitals

Question 18

Prescriber can be

Answer 18

physician, nurse practitioner, or pharmacist

Question 19

There are 5 types of orders:

Answer 19

routine
prn
STAT
now
prescriptions

Question 20

4 Distribution Systems

Answer 20

Stock supply system – meds available in large containers and meds must dispensed from each container by the nurse. I bottle of each medication and the nurse dispenses. High rates of errors. Not common.

Unit dose system – portable cart with drawer for each pt. 24hours of medications are supplied at a time. Medications are individually wrapped and labelled for each pt in their drawer. Controlled substances kept in a separate locked drawer. Less errors with dispensing meds

Automatic dispensing unit – computerized system (pyxis). Gain access with individual security code (fingerprint). Nurse must find pts profile and dispense meds from program. System will open specific drawer medication is located in. Bar codes can be scanned to identify pts or meds as well. All transactions are recorded.

Computers on wheels (COWs) – more cost effective and efficient. Cart with laptop mounted on it so it is portable. Diagnostic info always available. Can document at bedside. Can scan barcodes on pt and meds to decrease med errors.

Question 21

What is an incident report?

Answer 21

• Written account of incident (usually within 24 hours)
• Includes the patient identification information; the location and time of the incident; an accurate, factual description of what occurred and what was done; and the nurse’s signature
• Not a permanent part of the medical record and not referred to in the record
• Used to track incident patterns and to address quality improvement and risk management issues as necessary
• Disclosure to patients or family members: important

Question 22

4 components of critical thinking

Answer 22

• Knowledge – need to know why a medication was prescribed and how the medication will have its therapeutic effect. Admit what you don’t know and research.
• Experience – as you gain clinical experience you will be able to gain and apply knowledge
• Cognitive and behavioural attributes – must accept responsibility for your actions in regards to med admin. You must be familiar with the therapeutic effect, usual dose, laboratory references if there are any and adverse effects. You are accountable for what you administer so it is your responsibility to ensure it is done correctly.
• Standards – actions that ensure safe nursing practice. We use the 10 rights when administering medications. Every medication administered must be given according to the 10 rights.

Question 23

Ten Rights

Answer 23

The right medication
The right dose
The right patient
The right route
The right time and frequency
The right documentation
The right reason
The right to refuse
The right patient education
The right evaluation

Question 24

When do we compare the medication to the MAR?

Answer 24

always compare the label of the medication with the MAR 3 times:

1. before removed from the drawer,
2. when the medication is removed from the container,
3. before returning the container to its storage

Question 25

Before we give any medication we need to complete an assessment. This includes:

Answer 25

• Medical History A medication history reveals allergies, medications that the patient is taking, and the patient’s compliance with therapy.
• History of allergies – not only medical allergies, but food allergies must be documented as well. People with shellfish allergies can sensitive to products containing iodine such Betadine and CT contrast dye. Allergies must be noted in Admission notes, medication records and in the Pt History documentation completed by the physician.
• Medication data – all medication data must be reviewed. What medications for how long, the dosages, and adverse effects. What is the action, purpose, normal dosages, routes, adverse effects, and nursing implications for administration and monitoring. Is there any special instructions? Medication cards are used for this information. Need to know for each medication.
• Diet History – may be interactions with medications, can assist in dosage times.
• Patient’s perceptual or coordination problems – if there is physical limitations, may not be able to get pills to mouth, without dropping them,
• Patient’s current condition – if they are vomiting, is gravol PO the best choice?
• Patient’s attitude toward medication use
• Patient’s knowledge and understanding of medication therapy
• Patient’s learning needs (do they need drug education)

Question 26

Medication with kids

Answer 26

Children’s medication doses are computed on the basis of body surface area and weight. They are not packaged in standardized doses the way adult medications are. Children may need short simple explanations appropriate for their level of understanding. If they refuse, and it must be administered, do it quickly and carefully. Give the illusion of choice, do you want it with apple juice or orange juice, distractions, EMLA cream. Sometimes stickers or simple tokens work

Question 27

Medication with older adults

Answer 27

The older person’s body undergoes structural and functional changes that alter medication actions and influence the way in which medication therapy is provided. Box 34-17 and figure 34-13 summarize some of the special considerations with older age such as increased time of excretion, slower drug metabolism, decreased gastric motility (medications have longer to be absorbed), etc.