Chapter 31 (fundamentals Book)

Question 1

First American law to regulate medications

*requires all medications to be free of impure products

Answer 1

Pure Food and Drug Act

Question 2

Enforces medication laws that ensure that all medications on the market undergo vigorous testing before they are sold to the public.

Answer 2

Food and Drug Administration (FDA)

Question 3

Control medication sales and distribution; testing, naming, and labeling the use of controlled substances

Answer 3

Federal Medication Laws

Question 4

Set standards for medication strength, quality, purity, packaging, safety, labeling, and dose form

Answer 4

United States Pharmacopeia (USP) and National Formulary

Question 5

Protect the public from unskilled, undereducated, and unlicensed personnel.
*nurse is responsible for following legal provisions when administering controlled substances (opioids)

Answer 5

Nurse Practice Acts (NPAs)

Question 6

Provides and exact description of its composition and molecular structure
*nurses rarely use this form
Example: N-acetyl-para-acetaminophen (Tylenol)

Answer 6

Chemical name

Question 7

The manufacturer who first developes the medication gives this name
Example: Acetaminophen (Tylenol)
*becomes the official name listed in official publications (United States Pharmacopeia [USP])

Answer 7

Generic or Nonproprietary name

Question 8

The name under which a manufacturer markets a medication
*easily pronounced, spelled, and remembered
*similarities in these names are often confusing and lead to med errors (be careful to obtain the exact name and spelling for each med administered to pt)
Example: Tylenol

Answer 8

Trade or Brand Name

Question 9

Help healthcare providers easily recognize the difference between these commonly confused medications
Example: aMILoride and anLODIPine

Answer 9

Tall Man or Mixed Case Letters

Question 10

Indicates the effect of a medication on a body system, the symptoms a medication relieves, or its desired effect.
*each class contains more than one medication that is used for the same type of health problem
*some meds are in more than one class
Example: aspirin is an analgesic, antipyretic, and antiinflammatory medication

Answer 10

Medication Classification

Question 11

Medications are available in a variety of these

• it determines the medications route of administration
• tablets, capsules, elixirs, and suppositories
• be certain to use the proper form when administering

Answer 11

Medication Forms

Question 12

Enhances a medications absorption and metabolism

Answer 12

Composition

Question 13

Route of administration, ability of the medication to dissolve, blood flow to the site of administration, body surface area (BSA), lipid solubility medication, food in the stomach(medicine-food interactions), medications administers together (medicine-medicine interactions)

Answer 13

Factors that influence absorption

Question 14

• Topical medications: absorption is slow because of the physical makeup of the skin
• Oral medications: overall rate is slow because it must pass through the GI tract (acidic medications pass through the gastric mucosa rapidly; basic medications are not absorbed before reaching the small intestine)’
• Medications placed on the mucus membranes and respiratory airways: absorbed quickly because these tissues contain many blood vessels
• IM and SubQ medications: absorb more quickly than oral meds (IM enter bloodstream more quickly than SubQ)
• IV injection: produces the most rapid absorption because medications are available immediately when they enter the systemic circulation

Answer 14

Route of Administration and Absorption

Question 15

Depend on the physical and chemical properties of the medication and the physiology of the person taking it

Answer 15

Rate and Extent of Distribution

Question 16

After a medication reaches it site of action, it becomes a less active or inactive form that is easier to excrete

Answer 16

Metabolism

Question 17

Occurs under the influence of enzymes that detoxify, breakdown, and remove biologically active chemicals
*most occurs within the liver

Answer 17

Biotransformation

Question 18

Degrades many harmful chemicals before they become distributed to the tissues

• decrease in function occurs with aging or disease (medication is usually eliminated more slowly, resulting in accumulation)
• pts are at risk for toxicity if organs that metabolized medication are not functioning correctly

Answer 18

Liver

Question 19

After meds are metabolized they exit the body through the kidneys, liver, bowel, lungs, and exocrine glands
*chemical makeup of med determines the organ of exit

Answer 19

Excretion

Question 20

Gaseous and volatile compounds (nitrous oxide and alcohol) exit through the _________
*deep breathing and coughing help eliminate anesthetic gases rapidly after surgery

Answer 20

Lungs

Question 21

_____________ excrete lipid-soluble medications

• through sweat glands, the skin often becomes irritated, educated pt on good hygiene practices
• through mammary glands, risk that nursing infants will ingest the chemicals

Answer 21

Exocrine Glands

Question 22

Broken down by the liver and excreted into bile. After chemicals enter the intestines through the biliary tract, the intestines reabsorb them.

• factors that increase peristalsis (laxatives and enemas) accelerate med excretion through feces
• factors that slow peristalsis (inactivity and improper diet) often prolong the effects of medication

Answer 22

GI Tract and Hepatic Circulation

Question 23

Main organs for med excretion

• maintenance of an adequate fluid intake (50 mL/kg/hr) promotes proper elimination of meds for the average adult
• if renal function declines, the kidneys cannot adequately excrete medications, risk for toxicity increases (reduce med doses when this happens)

Answer 23

Kidneys

Question 24

The expected or predicted physiological response caused by a medication

• some meds have more than one ___________ effect
• knowing the desired _________ effect for each med allows you to be provide pt education and accurately evaluate the desired effect of a medication

Answer 24

Therapeutic Effects

Question 25

Undesired, unintended and often unpredictable responses to medication

• range from mild to severe, some happen immediately, some develop over time
• be alert and assess for unusual responses to meds, especially with new meds
• at risk are the very young, older adults, pregnant women, pts taking multiple meds, pts extremely underweight or overweight, and pts with renal or liver disease
• if meds are not tolerated and potentially harmful, stop giving meds IMMEDIATELY and report adverse effects to the FDA using MedWatch

Answer 25

Adverse Effects

Question 26

Predictable and often unavoidable adverse effect produced at usually therapeutic dose

• range from being harmless to causing serious symptoms or injury
• pts often stop taking meds because of this
• most common effects are anorexia, nausea, vomiting, constipation, drowsiness, and diarrhea

Answer 26

Side Effects

Question 27

Can develop after prolonged intake of a medication of when a med accumulates in the blood because of impaired metabolism or excretion

• excess amounts of a med within the body sometimes have lethal effects
• antidotes are available to treat specific types of toxicity

Answer 27

Toxic Effects

Question 28

Meds sometimes cause unpredictable effects

• pt overreacts or underreacts or a med or has a reaction different from normal
• it is not possible to predict whether a pt will have an ______________ response to a medication

Answer 28

Idiosyncratic Reactions

Question 29

Unpredictable responses to a med

• the med or chemical acts as an antigen, triggering the release of the antibodies in the body
• vary depending on the individual and the medication
• anaphylactic reactions: life threatening, sudden constriction of bronchiolar muscles, edema of pharynx and larynx, and severe wheezing and shortness of breath (requires immediate medical attention)

Answer 29

Allergic Reactions

Question 30

• Uticaria (hives): raised, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and pale centers
• Rash: small, raised vesicles that are usually reddened, often distributed over entire body
• Pruritus: itching of the skin; accompanies most rashes
• Rhinitis: inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge

Answer 30

Mild Allergic Reactions

Question 31

• Onset: time it takes after a medication is administered for it to produce a response
• Peak: time it takes for a medication to reach its highest effective concentration (highest level of concentration) (with IV infusions peak occurs quickly) (usually drawn whenever the med is expected to reach peak; varies)
• Trough: minimum blood serum concentration of med reached just before the next scheduled dose (lowest level of concentration) (generally drawn 30 mins before administering med)
• Duration: time during which med is present in concentration great enough to produce a response
• Plateau: blood serum concentration of med reached and maintained after repeated fixed doses

Answer 31

Terms Associated with Medication Actions

Question 32

Plasma level of a med below which the effect of the med does not occur

Answer 32

Minimum Effective Concentration (MEC)

Question 33

Level at which toxic effects occur

Answer 33

Toxic Concentration

Question 34

Achieve a constant blood level within a safe _________ range, falls between the MEC and the toxic concentration

Answer 34

Therapeutic Range

Question 35

The time it takes for excretion processes to lower the serum med concentration by half

Answer 35

Biological Half-Life

Question 36

To maintain this, a patient needs to receive regular, fixed doses

Answer 36

Therapeutic Plateau

Question 37

When teaching pt about dosage schedules, use familiar language
*twice-daily med=instruct to take one in the morning and one in the evening

Answer 37

Patient Education

Question 38

• before meals: AC,ac
• as desired: ad lib
• twice ea day: BID, bid
• after meals: PC,pc
• whenever there is a need: pm
• every morning: q am
• every hour: qh
• every day: Daily
• every 4 hours: q4h
• 4 times per day: QID, qid
• give immediately: STAT, stat
• 3 times per day: TID, tid

Answer 38

Common Dosage Administration Schedules and Abbreviations

Question 39

involves injecting medication into body tissues

Answer 39

Parenteral Administration

Question 40

1. Intradermal (ID) injection: into the dermis, just under the epidermis
   - typically used for skin tests (TB test, allergy tests)
   - med absorption occurs slowly
   - sites need to be lightly pigmented, free of lesions, and relatively hairless
   - ideal locations: forearm and upper back
   - angle of insertion is 5-15 degrees
   - small bleb (mosquito bite) appears on the surface of the skin
2. Subcutaneous injection (SubQ): into the dermis, just below the dermis of the skin
   - placing med into loose connective tissue under the dermis
   - med absorption is slower than IM injections
   - best sites are outer posterior aspect of upper arms, abdomen from below costal margins to iliac crests, and anterior aspects of the thighs
   - sensitive to irritating solutions and large volumes of meds (administer only small volumes [0.5-1.5 mL] of water soluble meds to adults and up to 0.5 mL to children)
   - typically use 25 gauge, 5/8 inch needle inserted at 45 degree angle OR use 25 guage, 1/2 inch needle insterted at a 90 degree angle
3. Intramuscular (IM) injection: into a muscle
   - deposits med into deep muscle tissue
   - med absorbs faster than SubQ, risk for injecting meds into blood vessels
   - meds not injected correctly into a muscle has complications such as; abscess, hematoma, ecchymosis, pain, and vascular and nerve injury
   - use a longer heavier gauge needle
   - angle of insertion = 90 degree angle
   - normal, well-developed adult pt tolerates 2-5 mL of med into larger muscle without severe discomfort (children, older adults and thin pts tolerate only 2 mL of IM injection)
   - rotate IM injection sites to decrease the risk for tissue hypertrophy
   - sites: Ventrogluteal (preferred and safest injection site for all adults, children, and infants especially for large-volume, viscous, and irritating meds), Vastus Lateralis (preferred site for immunizations to infants, toddlers, and children; muscle is thick and well-developed, located on the anterolateral aspect of the thigh; use middle third for injection), Deltoid (potential for injury; use for administration of immunization in toddlers, older children, and adults; three finger lengths below acromion process)
4. Intravenous (IV) injection: into a vein
   - infusion of larger volumes of IV fluid that contain meds mixed, labeled, and dispensed by pharmacy
   - injection of a bolus or small volume of med through an existing IV line
   - “piggyback” infusion of a solution containing the prescribed med and a small volume of IV fluid through existing IV line
   - when using this method observe pts closely for symptoms of adverse reactions
   - meds act immediately, no way to stop its action
   - take special care to avoid errors in dose, calculation, and preparation
   - asses vitals before, during, and after infusion
   - advantages: good for emergencies when needing a fast acting med that needs to be delivered quickly, best when necessary to give meds to establish constant therapeutic blood levels
   - verify rate of administration with a med reference or pharmacist before giving them to ensure you are give them safely over the appropriate amount of time
   - pts experience severe adverse reactions if IV meds are administered too quickly
   * if not done correctly, negative pt outcomes result (nerve or bone damage upon needle insertion)
   * use smallest suitable length and gauge, position pt as comfortably as possible, select proper injection site, insert needle quickly and smoothly to minimize tissue pulling, inject med slowly and steadily

Answer 40

Administering Injections

Question 41

• ea basic unit of measurement is organized into units of 10
• uses lowercase or capital letters or a combination of lowercase and capital letters to designate basic units
• gram (g), Liter (L), milliliter (mL), milligram (mg)
• deci (0.1), centi (0.01), milli (0.001)
• deka (10), hecto (100), and kilo (1000)
• always convert fractions to decimals (500 mg ——>0.5 g)
• a leading zero is ALWAYS placed in front of a decimal
• NEVER use a trailing zero (patient may receive 10x more med than prescribed)

Answer 41

Metric System

Question 42

1 mL = 15 drops (gtt)
5 mL = 1 teaspoon (tsp)
15 mL = 1 tablespoon (tbsp) 
30 mL = 2 tablespoons (tbsp) 
240 mL = 1 cup (c) 
480-500 mL = 1 pint (pt) 
960 mL (1L) = 1 quart (qt) 
3785 mL (4L) = 1 gallon (gal)

Answer 42

Equivalents of Measure

Question 43

Converting measurements w/in one system is relatively easy, simply divide or multiply in the metric system
Example: mg —>g (divide by 1000, move decimal 3 places left)
1000mg = 1 g
350mg = 0.35 g
Example: L —>mL (multiply by 1000, move decimal 3 places right)
1 L = 1000 mL
0.25 L = 250 mL

Answer 43

Conversions within One System

Question 44

The healthcare provider orders 500 mg of amoxicillin to be administered in a gastric tube every 8 hours. The bottle of amoxicillin is labeled 400 mg/5 mL
Proportion: 400mg / 5 mL = 500 mg / x mL
-cross multiply: 400x=500*5 ; 400x = 2500
-divide both sides by the number before x: 400x/400 = 2500/400 ; x=6.26 mL

Answer 44

Dose Calculations (proportion)

Question 45

Dose ordered x amount on hand = amount to administer
——————
Dose on hand

• dose ordered is the amount of med prescribed
• dose on hand is the amount of med supplied by the pharmacy
  
  • basic unit or quantity of the med that contains the dose on hand

Example: the healthcare provider orders morphine sulfate 2 mg IV. The med is available in a vial containing 10 mg/ mL.
2mg/10mg * 1mL = amount to administer
Amount to administer = 0.2 mL

Answer 45

Dose Calculations (Formula Method)

Question 46

An order for a med or medical treatment made over the telephone
-write “TO” when documenting

Answer 46

Telephone Order

Question 47

Med order given verbally

-write “VO” when documenting

Answer 47

Verbal Order

Question 48

• the nurse who took the order writes the complete order/enters it on a computer, reads it back, and receives confirmation form the healthcare provider to confirm accuracy
• nurse indicates the time and the name if the healthcare provider who gave the order, signs it, and follows agency policy to indicate that it was read back.
• healthcare provider counter signs the order later, within 24 hours after giving it
• *nursing students cannot take medication orders of any kind, they can give newly ordered meds only after an RN has written and verified the order

Answer 48

When order is received

Question 49

Carried out until the health care provider cancels it by another order or a prescribed number of days elapse. Some indicate a final date or number of treatments or doses.
Example: Tetracycline 500 mg PO q6h, decadron 10 mg daily x 5 days

Answer 49

Standing Orders or Routine Medication Orders

Question 50

When the healthcare provider orders a med to only be given when a patient requires it. Use subjective and objective assessment (severity of pain, body temp) and discretion in determining whether the pt needs the meds
Example: Morphine sulfate 2 mg IV q2h prn for incisional pain
-this order indicates that the pt needs to wait at least 2 hours between doses and can take the med if experiencing pain at the incision
-when administering document assessment findings to show why the pt needs the med and the time of administration
-frequently evaluate the effectiveness of the med and record evaluation data appropriately

Answer 50

prn Orders

Question 51

Healthcare provider orders a med to be given once at a specified time
-common for preoperative meds or meds given before diagnostic examinations
Example: Ativan 1 mg IV on call to MRI

Answer 51

Single (One Time) Orders

Question 52

Signifies that a single dose of med is to be given immediately and only once
-often written for emergencies when a pts conditions suddenly changes
Example: Apresoline 10 mg IV STAT

Answer 52

STAT Orders

Question 53

More specific that a 1-time order and is used when a pt needs med quickly but now right away
-nurse has up to 90 minutes to administer the med
-only administer med 1 time
Example: Vancomycin 1 g IV piggyback now

Answer 53

Now Orders

Question 54

Healthcare provider writes ___________ for pt who are to take meds outside the hospital
- includes more detailed information than med orders because the pt needs to understand how to take the med and when to refill if necessary

Answer 54

Prescriptions

Question 55

• do not delegate any part of the medication administration process to assistive personnel and use the nursing process to integrate med therapy into care
• inaccurate prescribing, administering the wrong med, giving the med using the wrong route or time interval, administering extra doses, and/or failing to administer a medication
• preventing med errors is ESSENTIAL
• nurses need to vigilant in preventing errors
• caused by many factors: technology work arounds, design of med labels, and medication distribution systems
• once pt is stable, report incident to the appropriate person in the agency, you are responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs. Report includes pt identification information; the location and the time of incident; an accurate, factual description of what occurred and actions taken; and signature
• report all med errors that reach the pt including those that do no harm
• also report near misses
• some errors happen when pts experience transition in care
  
  • reconcile med info to decrease likelihood of future error

Answer 55

Medication Errors

Question 56

1. Obtain, Verify, Document: obtain a comprehensive and current list of a pts meds whenever they experience a change in healthcare setting; include all current prescriptions, OTC meds, and homeopathic products
2. Consider and Compare: review what the pt was taking at home and make sure that the list of meds, dosages, and frequencies is accurate. Compare this list to the current ordered meds and treatment plan to ensure accuracy. Include family caregiver in this conversation when appropriate
3. Reconcile: compare new med orders with current list; investigate any discrepancies with the pts healthcare provider. Document any changes
4. Communication: ensure that all the pts healthcare providers have the most updated list of meds. Communicate and verify changes in meds as with the pt.

Answer 56

Process for Medication Reconciliation