Lecture 1&2 Pharmacology, the Nurses Role In Medication Administration Flashcards
What program does the FDA encourage for health care professionals to report a medication, product or medical event that causes serious harm to patients?
MedWatch program
Who regulates medication and nursing practice?
Nurse Practice Acts (NPA)
Are government control often more restrictive than health care agency policies?
No, healthcare agency policies are.
Chemical ( med. names)
Provides the exact description of medication’s composition, exact composition and molecular structure. (N-acetyl-para-aminophenol)
Trade (med. name)
Also known as brand or proprietary name. This is the name under which a manufacturer markets the medication (Tylenol)
Generic (med. name)
The manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia. (Acetaminophen)
Medication Classification
Indicates the effect of a medication on a body system
-Symptoms the medication relieves or desired effect.
Medication forms
Solid, liquid, other oral forms (topical, parenteral)
- compositions of a medication enhances its absorption and metabolism
Solid forms of medication
-Caplet (shaped like capsule, coated for ease of swallowing)
-Capsule
-Tablet
-Enteric-coated tablet (coated tablet that dissolves in intestine)
Liquid forms of medication
- Elixir:
Clear fluid containing water and/or alcohol - Extract:
Syrup or dried form of pharmacologically active medication, usually made by evaporating solution - Aqueous solution:
Substance dissolved in water and syrups - Aqueous suspension:
Finely dissolved medication particles dispersed in liquid medium; when suspension is left standing, particles settle to bottom of container - Syrup:
Medication dissolved in a concentrated sugar solution - Tincture:
Alcohol extract from plant or vegetable
Other Oral Forms and Terms Associated with Oral Preparations
- Troche (lozenge):
Flat, round tablets that dissolve in mouth to release medication; not meant for ingestion - Aerosol:
Aqueous medication sprayed and absorbed in mouth and upper airway; not meant for ingestion
-Sustained Release:
Tablet or capsule that contains small particles of a medication coated with material that requires a varying amount of time to dissolve
Medication Forms Commonly Prepared for Administration by Topical Route
- Ointment (Salve or cream): Semisolid, externally applied preparation, usually containing one or more medications
- Liniment:
Usually contains alcohol, oil, or soapy emollient applied to skin - Lotion:
Semiliquid suspension that usually protects, cools, or cleanses skin - Paste:
Medication preparation that is thicker than ointment; absorbed through skin more slowly than ointment; often used for skin protection - Transdermal disk or patch: Medicated disk or patch absorbed through skin slowly over long period of time (e.g., 24 hours)
Medication Forms Commonly Prepared for Administration by Parenteral Route
- Solution:
Sterile preparation that contains water with one or more dissolved compounds - Powder:
Sterile particles of medication that are dissolved in a sterile liquid (e.g., water, normal saline) before administration
Medication Forms Commonly Prepared for Instillation Into Body Cavities
- Intraocular disk:
Small, flexible oval (similar to contact lens) consisting of two soft, outer layers and a middle layer containing medication; slowly releases medication when moistened by ocular fluid - Suppository:
Solid dosage form mixed with gelatin and shaped in form of pellet for insertion into body cavity (rectum or vagina); melts when it reaches body temperature, releasing medication for absorption
Pharmacokinetics
The study of how medications enter the body, reach their site of action, metabolize, and exit the body. (Alter physiological functions)
(We use pharmacokinetics when timing medication administration, selecting the route of administration, and evaluating a patient’s response.
Four processes for Pharmacokinetics
Absorption
Distribution
Metabolism
Excretion
Where are medications absorbed/distributed in the patient’s body?
Cells, tissues, or a specific organ + alter physiological functions
Absorption
Occurs when medication molecules pass into the blood from the site of medication administration.
You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with:
A. absorption.
B. biotransformation.
C. distribution.
D. excretion.
Answer: D
Rationale:
The kidneys are the main organs for medication excretion. If a patient’s renal function declines, the kidneys cannot excrete medications adequately.
What is the rate of absorption when applying medication to the skin?
Absorption is slower because of the physical makeup of the skin.
Factors that influence absorption:
- Route of administration
- Ability of a medication to dissolve
- Blood flow to the site of administration
- Body surface area
- Lipid solubility
Absorption rate of mucous membrane and respiratory tract
Quick rate of absorption
-the tissues contain many blood vessels
What is the administration route of oral medication?
It is slow because its passing through the GI tract.
What medication has the most rapid response of absorption?
Intravenous injection/administration
-medication are available immediately when they enter the systemic circulation
What occurs after Absorption?
Distribution occurs within the body to the tissues, organs and specific site of action.
How does blood supply of the site of administration determine how quickly the body can absorb a drug?
The richer the blood supply to the site of administration, the faster a medication is absorbed.
When medication comes into contact with a larger surface, does it absorb slower or faster?
Faster
-Majority of medications are absorbed in the small intestine rather the large intestine.
Why do highly lipid soluable medications absorb quickly?
Because cell membranes have a lipid layer, allowing the medication to cross cell membranes easily and can be quickly absorbed.
What does the speed of distribution depend on? (Circulation)
Vascularity of various tissue and organs
-Once the medication has entered into the bloodstream, it is carried throughout the tissues and organs of the body.
Distribution depends on…
- Physical and chemical properties of the medication
-Physiology of the person taking it: Circulation, Membrane permeability, protein binding
Membrane permeability
Protein binding
The degree to which medications bind to serum proteins such as albumin affects their distribution.
How are medications metabolized?
Into a less-potent or an inactive form
-easier to excrete
What are older adults/patients with liver disease or malnutrition at risk for when taking medication?
They have an increase risk of medication activity, toxicity or both because these conditions decrease albumin in the bloodstream
-Most medications binds to albumin (a type of protein) to some extent and then cannot be pharmacologically active.
How is a medication unbound or “free”?
Part of the medication that aren’t bound to protein are the active form of medication.
Where does most biotransformation occur?
Liver
Biotransformation
occurs under the influence of enzymes that detoxify, break down, and remove biologically active chemicals
Why is the liver important in metabolism?
The liver has a specialized structure that oxidizes and transforms many toxic substances.
- the liver degrades many harmful chemicals before they are distributed to the tissues.
What other parts of the body does biotransformation occur, other than liver?
Lungs, kidneys, Blood and Intestines
What are patients at risk for if their organs that metabolize medications are not functioning correctly?
Medication toxicity
-If any of these organs are not working properly, medications won’t be broken down as effectively, which can lead to a build-up of the drug in the body, increasing the risk of toxicity.
Metabolism
How the body breaks down the medication, usually in the liver, into active or inactive forms.
- Medications are changed into less potent or inactive forms through a process called biotransformation.
Distribution
How the medication travels through the body to reach cells, tissue, or organs
Excretion
How the medication is eliminated from the body, primarily through the kidneys.
Impairment of what two organs can increase the risk of medication toxicity?
Liver (Metabolism) and kidney (Excretion) function
What is the main organ for excretion?
Kidney
Which type of medications are excreted through the lungs?
Anesthetic gases and alcohol
Why should certain medications not be taken during pregnancy?
Some may pass through the placental barrier or mammary glands.
Medications exit the body through the…
Kidney - main organ for excretion
Liver - breaks down medications from hepatic circulation
Bowel - after chemicals enter intestine through biliary tract, the intestines resorb them
Lungs - medications excreted anesthetic gases (ex nitrate oxide) and alcohol
Exocrine glands - examples sweat salivary glands excrete lipid soluble medications (sweat, salivary, mucous, mammary)
Types of Medication Action
- Therapeutic effect
- Adverse effect (Side effect, toxic and idiosyncratic reaction)
- Allergic reaction
- Medication interactions
+Medication tolerance and dependence
Therapeutic effect
Expected or predicted physiological response
Adverse effect
Unintended, undesirable, often unpredictable
Side effect (adverse)
Predictable, unavoidable secondary effect
Toxic effect (adverse)
Accumulation of medication in the bloodstream
Idiosyncratic (adverse)
Overreaction or under-reaction or different reaction from normal
How can patients react to adverse drug effects?
Depending on patients, it can be mild to sever. Some effects can be immediate, whereas others can develop over time. (unpredictable effect)
How can toxic (adverse) effect patients?
Often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion.
How can specific type of medication toxicity be treate?
Antidotes
Allergic reaction
unpredictable response to a medication
Medication interactions
when one medication modifies the action of another
How can patients who cannot communicate alert health care providers that they are allergic to certain medications when given care?
Identification bracelet or medal
Synergistic effect
When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately.
ex: a drug A decreases cancer growth by 10%, drug B decreases it by 20%, combining the two drugs decreases cancer by 35% or more
What is a more severe version of an allergic reaction and what happens?
Anaphylactic reactions (Anaphylactic shock):
life threatening reaction characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath.
A postoperative patient is receiving morphine sulfate via patient-controlled analgesia (PCA). The nurse assesses that the patient’s respirations are depressed. The effects of the morphine sulfate can be classified as:
A. allergic.
B. idiosyncratic.
C. therapeutic.
D. toxic.
D
Rationale:
- Toxic effects often develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Excess amounts of a medication within the body sometimes have lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause severe respiratory depression and death.
Timing of Medication Dose Responses (7)
- Therapeutic range-when a medication is prescribed, the goal is to achieve a constant blood level within a safe range between minimum effective range and toxic range
- Peak-highest level of medication
- Trough-lowest level of medication
- Biological half-life-time it takes for excretion processes to lower the amount of unchanged medication by half
- Plateau-to be reached patient needs regular fixed doses of medication
- Time-critical medications-medications in which early or delayed administration of maintenance doses (more than 30 minutes before or after the scheduled dose) will most likely result in harm or sub therapeutic responses in a patient
- Patient teaching-importance of taking medication at the correct times
Minimum Effectice Concentration (MEC)
The plasma level of a medication below which the effect of the medication does not occur.
Sublingual Administration
Some medications (e.g., nitroglycerin) are readily absorbed after being placed under the tongue to dissolve.
-instruct pt to not swallow or drink water till completely dissolved; ensures desired effect
Buccal Administration
Administration of a medication by the buccal route involves placing the solid medication in the mouth against the mucous membranes of the cheek until it dissolves.
-instruct pt to alternate cheeks with each subsequent dose to avoid mucosal irritation.
Disadvantage/Contraindication of oral, buccal, sublingual routes
Oral route is avoided when patient has alterations in gastrointestinal (GI) function (e.g., nausea, vomiting), reduced GI motility (after general anesthesia or bowel inflammation), and surgical resection of the GI tract.
Oral administration is contraindicated in patients unable to swallow (e.g., patients with neuromuscular disorders, esophageal strictures, mouth lesions).
Oral administration is contraindicated in patients who are unconscious, confused, or unable or unwilling to swallow or hold medication under tongue.
Oral medications cannot be administered when patients have gastric suction; are contraindicated before some tests or surgery.
Oral medications sometimes irritate lining of GI tract, discolor teeth, or have unpleasant taste.
Gastric secretions destroy some medications.
Parenteral routes: Four majore sites of injection
- Intradermal:
Injection into the dermis just under the epidermis (Example TB test/PPD) - Subcutaneous:
Injection into tissues just below the dermis of the skin - Intramuscular:
Injection into a muscle - Intravenous:
Injection into a vein
Other routes of parenteral
- Epidural: Is a numbing medicine anesthetic)given by injection (shot) in the back/cerebrospinal fluid It numbs or causes a loss of feeling in the lower half your body)
- Intrathecal: Spinal canal
- Intraosseous: Marrow of the bone
- Intraperitoneal: Injection into the peritoneal cavity/body cavity
- Intrapleural: Medication administered into the chest in the pleural space
- Intraarterial: Medication administered directly into the arteries
What other routes are limited to physicians?
Intracardiac (injection into the cardiac tissue) and intraarticular
Areas of the Topical Administration
Skin and Mucous membrane (local effects)
How can topical administration cause a systemic effect?
A patients skin is thin or broken down, the medication concentration is high or contact with the skin is prolonged.
What effect does a transdermal disk or patch have? (e.g., nitroglycerin, scopolamine, and estrogens)
Systemic effects
-can be left in place from 12 hours to 7 days
Intramuscular Injections
- Faster absorption than subcutaneous route
- Many risks, so verify the injection is justified
- Angle of administration: 90 degrees
Body mass index (BMI) and adipose tissue influence needle size selection
Intradermal Injections
Used for skin testing (tuberculosis [TB], allergies)
Slow absorption from dermis
Skin testing requires the nurse to be able to clearly see the injection site for changes
Use a tuberculin or small hypodermic syringe for skin testing
Angle of insertion is 5 to 15 degrees with bevel up
A small bleb will form
Intravenous Administration: Three methods
- As mixtures within large volumes of IV fluids
- By injection of a bolus or small volume of medication through an existing IV infusion line or intermittent venous access (heparin or saline lock)
- By “piggyback” infusion of a solution containing the prescribed medication and a small volume of IV fluid through an existing IV line
The Needlestick Safety and Prevention Act
Mandates the use of special needle safety devices to reduce the frequency of needlestick injuries
How are drug classification schedule organized?
Into groups based on risk of abuse or harm
Schedule 1 drugs
Drugs with high risk and with no counterbalancing benefit are not accepted from medical practice/use in the United States
-heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”).
How are substances placed in the five schedules by the Controlled Substance Act?
Based on…
- Whether they have a currently accepted medical use in treatment in the United States
- Their relative abuse potential
- Likelihood of causing dependence when abused.
Schedule II/IIN
Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.
- Examples of Schedule II narcotics include: hydromorphone (Dilaudid), methadone (Dolophine), meperidine (Demerol), oxycodone (OxyContin, Percocet), and fentanyl (Sublimaze, Duragesic). Other Schedule II narcotics include: morphine, opium, and codeine.
- Examples of Schedule IIN stimulants include: amphetamine (Dexedrine, Adderall), methamphetamine (Desoxyn), and methylphenidate (Ritalin).
Schedule III/IIIN
Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.
- Examples of Schedule III narcotics include: combination products containing less than 15 milligrams of hydrocodone per dosage unit (Vicodin), products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine), and buprenorphine (Suboxone).
- Examples of Schedule IIIN non-narcotics include: benzphetamine (Didrex), phendimetrazine, ketamine, andanabolic steroidssuch as Depo-Testosterone.
Schedule IV Controlled Substances
Substances in this schedule have a low potential for abuse relative to substances in Schedule III.
Examples of Schedule IV substances include: alprazolam (Xanax), carisoprodol (Soma), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), midazolam (Versed), temazepam (Restoril), and triazolam (Halcion).
Schedule V Controlled Substances
Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.
Examples of Schedule V substances include: cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC, Phenergan with Codeine), and ezogabine.
What do nurses use solutions of various concentration for?
Injections, irrigations and infusions
Solution
a given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid.
Who can prescribe medication?
Physician, nurse practitioner or physicians assistant
How can orders be given?
Written (hand or electronic)
Verbal
Given by telephone
Standing or routine order
Administered the same time and dosage until the dosage is changed or another medication is prescribed or canceled
PRN order
As needed
Single (one-time)
Given one time only for a specific reason
STAT order
Give immediately in an emergency
Now order
When a medication is needed right away, but not a stat
Prescription order
Medication to be taken outside of hospital
How long does the nurse have to administer a new order for a “Now order”?
90 minutes
Pharmacists Role
Prepares and distributes medication
Nurses Role
- Determine medication orders are correct
- Assess patients ability to self-administer
- Determine whether patient should receive medications at a given time
-Administering medications correctly - Closely monitor/evaluate effects
- Patient/family teaching of medication
- Nurses cannot delegate medication to NAP
Uni-Dose System
Storage system that varies by health care agency.
AMDS
Automatic Medication Dispensing System
Other than not paying attention to giving medication causing med error, what is another situation a med error can occur?
Some medication errors happen when patients experience a transition in care such as when a patient is admitted or discharged from a hospital, is transferred from an intensive care unit to a general patient care unit, or sees a new health care provider. During these times the risk of unintended changes in medication orders increases. Thus reconciling medication information is a key Hospital National Patient Safety Goal.
Medication Reconciliation
Nurses, pharmacists, and other health care providers compare the medication that a patient is taking currently with what the patient should be taking and any newly ordered medications. Throughout this process you identify and resolve orders that are duplicated and omitted.
-Accurate medication reconciliation requires consulting with the patient, family caregivers, other clinicians, pharmacists, and other members of the health care team.
Seven Rights
- Right medication
- Right dose
- Right patient
- Right route
- Right time
- Right documentation
- Right reason
A patient has the right to…
- To be informed about a medication
- To refuse a medication
- To have a medication history
- To be properly advised about experimental nature of medication
- To receive labeled medications safely
- To receive appropriate supportive therapy
- To not receive unnecessary medications
- To be informed if medications are part of a research study
What do you document after administering medication?
Name of medication, the dose, the time of administration, and the route (on the MAR).
+ Document site of any injections and the patients response to medication, either positive or negative
What do you do before administering new medications to patient?
-Review patient medical history for allergies, contraindication/indication
-Patients diet history to plan an effective and individualized medication dosage schedule
-See if patient can self-administer
-Assess a patient physical and mental status
-Teach patient about the medication
