Fund Week 3 - medication administration Flashcards
Medication Legislation and Standards (the legislation controls my drugs, 2 nurses, and the pharmacy)***
➢ Regulates controlled substances
➢ Set standards for 2 RN checks for high alert medications
➢ Regulates pharmaceutical industry to protect public health by
ensuring medication safety and effectiveness
State Nurse Practice Act (NPA) (the practice defines the scope)
➢ Influences nursing practice and defines SCOPE of practice
(Functioning beyond scope of practice or skills = malpractice)
➢ Nurses may be partially responsible regardless of erroneous
order written by a provider
Adverse drug reactions (ADR) (the simplest explanation)
Harm experienced by a patient as a result of exposure to a medication
Adverse drug reactions - (my reaction is unintentional)
Preventable or unintentional
▪ Accounts for nearly 700,000 ED visits (25% are elderly) and
100,000 hospitalizations and deaths/year (~ 50% of hospitalizations due to ADE’s are the elderly)
▪ Transitions in care are well-documented source of preventable harm related to medications
Medication Errors-what to do (VS, notify, tell, report, root cause)***
- Assess the patient’s VS and any other symptoms
- Notify the primary care team, charge nurse and manager
- Inform the patient and family
- Complete an Incident Report
- Root cause analysis for sentinel
Risk factors for ADE’s (adverse drug event) (age, weight, renal, confusion, dehydration)
▪ Polypharmacy strongest risk factor
▪ Age/Life span
▪ Pediatrics – immature renal function
▪ Pregnancy and breast milk– some drugs cross the placenta and milk
▪ Geriatrics – more fat storage and functional, and cognitive and functional impairment
▪ Obesity and extreme underweight
▪ Impaired renal or hepatic function
▪ Poor health literacy
▪ Receiving treatment from multiple providers
▪ Comorbidities
▪ Confusion/cognitive dysfunction
▪ Dehydration/rapid hydration
geriatric considerations
•↑Comorbidities
•Physiological changes
-cognition change
- Vision/hearing impairment
- Dexterity
•↑adipose tissue, Low metabolism
•Dehydration more common
•Polypharmacy
•Poor compliance
•Drug interaction and Adverse reactions
•Inappropriate prescribing
▪Studies found older adults fail to adhere to their medication regimens as much as 60% of the time
▪START/STOPP Medications criteria in the Elderly:
▪STOPP (Screening Tool of Older Persons’ Prescriptions)
▪START (Screening Tool to Alert to Right Treatment)
Medications and Patient Safety
10,000 prescription medications available to clinicians (AHRQ 2017)
❖1/3 of adults take ≥ 5 medications
❖Institute of Safe Patient Practices implemented safe practices:
■Spell out SALADs (Sound Alike, Look Alike, Drugs) which have significant patient harm if used incorrectly
Distribution dependent on: (distribute if blood is good, protein is good, and can you get across the BBB)
- Blood circulation
- Protein binding (can drug leave circulation or is it stored in tissue)
- Permeability of the Blood Brain Barrier (BBB)/Placenta
2021 Hospital National Patient Safety goals (goal to communicate ID w/ safe med administration)
1 Improve accuracy of patient identification
▪ #2 Improve staff communication
▪ #3 Improve the safety of medication administration
Follow 6 rights of medication administration
- Right patient
- Right medication
- Right dosage
- Right route
- Right time
- Right to refuse
- Right documentation
other Rights - Right assessment
- Right education
- Right response
drug nomenclature
Chemical Name: the exact description of the drug’s chemical composition and molecular structure
-e.g. 2-(p-isobutylphenyl) propionic acid = ibuprofen
Generic name (nonproprietary): Assigned by the manufacturer that first developed the drug; identifies the drug’s active ingredient e.g.
Acetaminophen or Ibuprofen
Brand name (also trade or proprietary): selected by the
pharmaceutical company that sells the drug and is trademarked
e.g Tylenol and Advil
*Nurses should become familiar with both
Components of Drug Order (ordering drugs is DDDRT SSH)- (just what should be your script - your name, etc)
Patient’s full name
❖ Date and time of order
❖ Drug name-usually contains generic and brand name
❖ Dose
❖ Route
❖ Time and frequency of administration (may contain a stop
date/time order)
❖ Scheduled, continuous, prn, one time
❖ Name/Signature of ordering provider
❖ Hold and titrating parameters if appropriate
the 3 checks for meds
1st check:
Compare eMAR to the medication dispensing machine screen (select meds needed: check drug name, dose, route, and time due)
2nd Check:
Pull the selected medication out of dispensing drawer and compare drug against the dispensing display (check the drug name, dose, route, and expiration date of med)
Performed in patient Room
3rd Check:
At the bedside: scan pt armband, check name, DOB, allergies, drug name, dose, route, time against eMAR
- Right Patient
➔ 2 Identifiers: Verify patient’s name/MRN and DOB on the ID band
➔ Then scan barcode and check the patient identifiers against the MAR
➔ Verify patient’s recorded allergies and allergy wristband present
- Right Drug
➔ Compare drug name against patient’s MAR
➔ Pay attention to SALADs (Sound- A-Like Look-a-Like
Drugs)
◆ E.g. hydralazine vs hydroxyzine and dopamine and dobutamine
➔ Does it make sense for patient to receive this
drug
Right Dose
➔ Check label for medication dose
➔ Double check all medication calculations
◆ (be alert to units- 1mg vs 1mL, 0.125mg = 125mcg)
➔ 2 independent RN checks for high alert meds-(insulin,
narcotics, heparin)
➔ Question inappropriate dose
Right Route
➔ Evidence shows errors involving wrong route is most
common
➔ Verify medication route with medication order; only
administer via route specified in the order
➔ If giving IV medication, follow medication bag to tubing to
site
➔ Assess for appropriateness of route ordered
Right Time (and confirm something in the charts…)
➔ Verify medication time with order
1. Date
2. Time
◆ Check last dose of medication given to patient
◆ Hospitals now have one hour window before and after the actual scheduled time to administer meds; check your facility
3. Verify specific infusion time if medication is IV infusion
Right Time on call
➔ “On call”-given peri-operatively or pre-procedure
➔ STAT-give immediately
Should no longer be used – but
good to know if it comes up
➔ ac- before meals (from the Latin word “ante cibum”)
➔ pc- after meals (from the Latin word “post cibum”)
➔ hs – at bedtime (from the Latin word “hora somni”)
right time ➔Scheduled/Standing order (these are just examples)
➔Scheduled/Standing order
➔Single/One time order
Example: Tylenol 1000mg (2 tabs
of 500mg) by mouth x 1 (once)
➔ Prn- meaning as needed (from Latin phrase “pro re nata”)
Example: Nitroglycerin 0.4mg tab, sublingual every 5min x 3 prn chest pain
right documentation - what are you documenting?
➔ Never document before medication is administered.
Document at the bedside after the medication is taken. – RN must see patient take meds
➔ Document parameters-pain scale before and after
medication, vital signs, lab results as indicated
➔ Document reason for med not given (patient refused, patient off unit, med not available at scheduled time, nausea, etc.)
➔ Hospital policy – inform MD of refusal
Right Documentation
Document in MAR
- Medication
- Dosage
- Route
- Date and time
- Signature and credentials
- When appropriate, signature of other nurse checking
medication - Parameters if appropriate
Other Medication Rights: Education (educate the right effect and right precautions)***
➔ During medication administration, inform patient of purpose/desired effects of each medication
➔ Teach the patient to report significant side effects related to medications Educate patient about any special precautions with medication (Insulin, anticoagulants, opioids, etc.)
Medication: Right to Refuse
● The patient as well as the patient’s legal guardian (parent, family member, guardian) for patient’s care has the right to refuse any medication
● Inform responsible party consequences of refusing medication and verify that responsible party understands Document that MD was notified of patient refusal
● Document that patient or responsible party refused
med and that he/she was informed of the potential consequences
Medication: Assessment - what to assess? (hx, vs, etc)***
● Gather hx
● Many medications require specific assessments prior to administration-VS, apical pulse, bowel activity, pain level, lab values
● Many medications have parameters for administration or holds-cardiovascular medications, opioids, insulin sliding scale, anti-hypertensives and stools softeners
Antihypertensives: - when to hold
○ Know current BP and HR administration (within 30min): generally hold for SBP <100, HR <60
○ Some antihypertensives have no specified hold parameters; use judgment
Diuretics: - what to check for? (you’ve had personal experience)
○ Check BP and Creatinine level
○ Check K and Mg level (hold and report if <3.5 mEQ/L)
○ Monitor I and O
○ Assess weight esp for patients with heart failure
Digoxin (digging for a new heart) what to do before giving to patient? (And what else? Same as spiro)
Digoxin-for heart failure; Take APICAL pulse for 1 min;
Check Potassium Levels – low K+ ↑ risk of digitalis (this is just digoxin) toxicity
Laxatives/stool softeners - what to ask about
○ Assess number of BMs and
consistency. Any GI
discomfort?
Nitrates -when to hold
Nitrates-hold SBP < 100
Heparin infusion - what to check before giving - hepburn loves Pilates
Know platelet count (Heparin may induce thrombocytopenia “HITT)
○ IV Heparin- check aPTT
Warfarin (check INR) - what is the antidote? (Think, what clots blood)
○ antidote Vitamin K
Insulin: Check blood sugar
(meal tray present and pt eating, prn glucose for hypoglycemia)
Narcotics: Respiratory rate, pain, LOC - antidote - you already know this
○ antidote IV or inhaled narcan
Inhalers/Nebulizer treatments - what to do before and after albuterol - think LUNGS
○ lung sounds, RR, O2 sat before and after (Albuterol will increase HR)
Antibiotics: (you know this - AND antibotics have highs and lows)
know cultures, WBC, temperature, any diarrhea, peak and trough levels, renal function (BUN/Cr)
Evaluate Treatments (document, paln, I/O, BP, adverse reaction)
● Document effectiveness
○ Pain level after pain medication
○ Urine output after diuretics
○ BP after anti-hypertensive
● Adverse Drug Reactions if any
Major Routes of Med Administration
Enteral routes
*PO, SL, PR
Parenteral routes
*IV, IM, SC, ID
Intraperitoneal
Intrathecal
Intramedullary
Intraarterial
Intraarticular
Intracardiac
*Epidural
Inhalation
*Inhalers and
nebulizers
*Transdermal
NTG, Fentanyl,
Estrogen, Nicotine
*Topical route
Droplets (Nasal,
Otis ophthalmic)
Vaginal
Urethral
oral route - considerations
It’s the route of choice
Considerations:
● Persons with high aspiration risk (dysphagia and have AMS)
● Nausea/vomiting
● Potential for low absorption/short gut syndrome
● Nasogastric tube suctioning (stop suction, give meds, and wait 30 minutes before resuming)
Certain medications have better absorption taken before meals or with food to minimize GI upset
● Keep medicine cup at eye level when pouring liquids
Medication via Feeding tube
● Check for “OK to use” order after verified by xray
● Tube placement secured at documented length
● If medication is to be given on an empty stomach, allow at
least 30” before restarting feeding
● If NGT to suction in place, stop suction for 30 min for
medication to absorb before resuming suction
Check residual before med admin if patient getting tube
feeding
● Flush with 30 mL of water before first med and after giving last medication
● Give one med at a time and flush with 5 ml water between medications
Topical Nitroglycerin
Given for chest pain
⚫ Do not get on hands!!!
⚫ Squeeze ointment onto paper
with designated markings
⚫ Ordered in inches as marked on
paper
⚫ Cover with tape, date, time,
and your initials
⚫ Evaluate effectiveness
Inhaled Medications
● Use Metered Dose Inhaler (MDI) for children or adults who
can’t keep inhaled medication in
● Clean mouthpiece prn
● Recommend to wait one minute between puffs of inhalers
● Always rinse mouth after steroid inhalers to minimize risk of
thrush oral (yeast infection)
Nebulized Albuterol Respiratory Medications
● Assess HR, RR, O2 saturation and lung sounds before and
after treatment
● Inform patient may cause nervousness, palpitations, or
tremors
● Use either O2 or compressed air for treatments
● In most hospitals, administered by respiratory therapist
Parenteral Medications (and what technique is required)
● IV, IM, SQ, ID
● Other routes: intraspinal, intrathecal, epidural
● Requires aseptic technique
Drawing Medication from Vial
● Remove cap
● Scrub top of vial with alcohol for 10 secs
● Attach blunt needle or filtered needle if drawing from an ampule
● Draw up air equal to the volume to be given
● Insert the needle pointing downward into the vial on a stable surface, and invert to draw up solution
Syringe/Injection Basics
● Remove air bubble before injecting the solution. Debate whether there should be 0.2mL dead space pulled into syringe
● Give SQ injections 2 inches from umbilicus
○ Other locations: back of arms; thighs not preferred
● Treat the needle like a loaded weapon and immediately place in
sharps container
Insulin Administration***
● Use only designated insulin syringe for injections
● Newer injections: Insulin pens
● Assess dietary intake and check finger stick blood sugar before
administration
● Rotate sites to prevent lipodystrophy
● Insulin needle is very fine and can bend easily…
● Air is frequently a problem after drawing up solution if drawing
from vial
Risk Factors for Hypoglycemia***
Incorrect insulin dosing, timing, or type of carbohydrate intake
● History of severe hypoglycemia
● Older adults
● NPO
● Abrupt TPN or tube feeding reduction or termination
Use of oral antidiabetic agents or insulin
● Hepatic impairment
● Hypoglycemia
unawareness
● Excess ETOH (alcohol)
● Emesis (vomiting)
● Strenuous exercise
● Weight loss without medication adjustment
Age Related Risk Factors-Geriatric - hypoglycemia***
● Risk for severe/fatal hypoglycemia with Oral
Hypoglycemic Agents (OHA) and insulin use increases
exponentially in the elderly population
● Comorbidities
● Polypharmacy
● Dementia/Alzheimer’s
● Vision/ dexterity decline
Elderly individuals may have hypoglycemia unawareness
● Blood glucose may continue to drop and
reach serious neuroglycopenic levels
(BS < 40 mg/dl) before it is recognized and treated
Hypoglycemia (the numbers)***
⚫ Approximately 90% of all persons receiving insulin experience hypoglycemic reactions
⚫ This threat is the major limiting factor for intensive glycemic control
in both Type I and Type II DMADA 2018 Glycemic target:
Non diabetic Glucose target:
Fasting 60-100 mg/dl
After meals < 140 mg/dl
Diabetic Glucose target:
Fasting 70-130 mg/dl
After meals < 180mg/dl
*More permissive hyperglycemia in diabetics
Intervention for Hypoglycemia***
Rule of 15
● Conscious patient-15 g of carbohydrate
○ 3 hard candy, 3 glucose tabs, 4 oz. apple juice or OJ
(OJ not appropriate for renal patients)
● Recheck blood sugar in 15 min
● Repeat treatment every 15 min x3 until BG >120 mg/dL
● Once glucose is stable give complex carbohydrate to prevent rebound hypoglycemia
Intervention for Hypoglycemia
Rule of 15
● If symptoms persist after 3 rounds of quick acting CHO
● Worsening sx or Decreased LOC/Unconscious patient
Immediate IV access to administer 25g (50 mL) IVP of
50% DextroseIf unable to obtain IV access, administer 1 mg of glucagon
IM or SQ
Once patient recovers, important to determine cause
Type II Diabetics (3 Ps - eat)
● 80% of diabetes are type II
The 3 Ps
○ Polyuria
○ Polydipsia - very thirsty
○ Polyphagia - eats a lot
● Fatigue
● Headache
● Blurred vision
Type I (not the main one) NV SOB weak, confused)
•Fruity sweet breath if ketones
present (DKA-ketone bodies)
•Nausea and vomiting
•Shortness of breath
•Dry mouth
•Abd pain
•Weakness
•Confusion
•Coma
SQ Injections Using Tuberculin
Syringe (size of syringe)
● Tuberculin syringe=1 ml
syringe
● Used for both ID (allergy/TB
testing) and SQ injections of
Heparin, Epinephrine
● Needle sizes generally 25-28
gauge, 1/2-5/8 inch.
● Bariatric patients may need
longer needles
● Bariatric patients may need
longer needles
● Package will state that it is
a tuberculin syringe
● Usually has a red or
orange cap
● Maximum volume for SQ
injection is 1 ml
IM Injections – Z track Technique (Z track is large)
● Seals the needle track and prevents medication leaking from
muscle to SQ tissue
● Recommended for all IM injection in the larger muscles:
ventrogluteal, vastus lateralis, dorsal gluteal
● Less painful especially with irritating medications
Should You Aspirate IM
Injections?(drawupblood)
Recent studies showed no clear evidence, however here are some recommendations from systematic literature reviews:
1.Aspiration not indicated for SQ injections
2.Aspiration is not indicated for IM injections of vaccines and immunizations
3.Aspiration may be indicated for IM injections of large molecule medications, such as penicillin
4. If you do aspirate a small amount of blood in the syringe, stop the injection, get new needle and syringe and start the procedure over
Review: Intramuscular Injections***(what size needle for muscles)
● Most appropriate site for >1mL injection: Ventrogluteal
New Practice:
**Aspirating prior to IM injection is not necessary; now
recommended only for dorsogluteal site d/t proximity to
gluteal artery
NCBI – National Center for Biotechnology Information
For clinical rotation - Be prepared to discuss the
following: (DIABET)
● Research all medications thoroughly for clinical preparation
○ Is the dosage within range and route appropriate?
○ The basic action/therapeutic effect
○ Indications
Most common adverse effects
● Black box warnings
● Nursing assessments prior
and post administration
● Patient/Family Education
For clinical rotation:
● Have all your assessment information
available prior to preparing medication
○ Vital signs, pain level, labs, last bowel movement, etc.
● IV therapy is taught next semester. Assess IV site for redness,
swelling, tenderness, or warmth. Verify solution and rate are
as ordered
Federal, state, and local standards
➢ Regulates controlled substances
➢ Set standards for 2 RN checks for high alert medications- e.g.
insulin, heparin
➢ Regulates pharmaceutical industry to protect public health by
ensuring medication safety and effectiveness
Medications and Patient Safety
10,000 prescription medications available to clinicians (AHRQ 2017)
❖1/3 of adults take ≥ 5 medications
❖Institute of Safe Patient Practices implemented safe practices:
■Spell out SALADs (Sound Alike, Look Alike, Drugs) which have significant patient harm if used incorrectly
■High alert meds: Heparin, Insulin, narcotic drips and certain chemo medications require 2 RN check
2 types of adverse drug reactions (adverse reactions - PU!)
Preventable or unintentional
medication errors can lead to…
sentinel events and even death
DONT FORGET TO CHECK FOR….
allergies
if you’re giving digoxin, you always check the..
apical pulse first
high alert meds (not the drooling, this is just 4)
insulin, heparin narcotic drips and certain chemo medications
ex of adverse drug reaction (ativan is adverse)
Ex - ativan can make elderly ppl more agitated and delirious or cancer drugs weaken immune system
strongest risk factor for ADE
Polypharmacy strongest risk factor
most common med error involves what?
the route
during assessment - when to gather history and meds?
on admission, during transitions in care, and upon discharge (done by physician)
antidote for heparin (prototype for heparin)
Protamine
examples of adverse drug reactions (ADR) (reaction to OD)
➔ medication administration errors
➔ allergic reactions
➔ overdose
Side effect (secondary effects): Usually mild
and predictable
insulin administration
clear before cloudy -
Inject Air into NPH Insulin (Cloudy) …
Inject Air into Regular Insulin (Clear) …
Withdraw Regular Insulin Units. …
Withdraw NPH Units. …
