ADMINISTRATION OF MEDICATIONS MODULE 6

Administering drugs is one of most critical nursing responsibilities. Smallest margin for error Administering drugs is one of your most critical nursing responsibilities. It is the area with smallest margin for error

Medication Administration Avoiding errors: know how to read & correctly interpret drug orders have a sound understanding of pharmacology. Pharmacology is the study of drugs & their action on living organisms

Drug chemical, generic & trade names The chemical name (p-Acetaminophenol, Paracetamol, p-Hydroxyacetanilide:N-acetyl-p-aminophenol) provides an exact chemical description of the drug’s composition. The manufacturer who first develops the drug gives the generic name (acetaminophen) before it receives official approval Item No. Proper Names Chemical Names and Synonyms A.1 Acepromazine 2-acetyl-10-(3-dimethylaminopropyl) phenothiazine A.2 Acetaminophen p-Acetaminophenol, Paracetamol, p-Hydroxyacetanilide: N-acetyl-p-aminophenol

Drug chemical, generic & trade names Federal legislation in 1962 mandated that there is one official name (acetaminophen) for each drug. A drug’s generic name often becomes its official name The trade name (Tylenol), brand name, or proprietary name is the name under which a manufacturer markets a drug. A generic drug may have many different trade names (Tylenol, Atasol, Tempra are all trade names of acetaminophen products)

Acts/laws regulating drugs in Canada Laws govern all aspects of drug production, distribution, advertising, and sale. The Canadian drug laws Food and Drugs Act of 1953 Narcotic Control Act of 1961 (p.1116). Both laws under the Health Protection Branch of Health Canada. Enforcement of Narcotic Control Act delegated to the RCMP From Du Gas, p. 1116, 2nd edition, Laws govern all aspects of drug production, distribution, advertising, and sale. The Canadian drug laws include the Food and Drugs Act of 1953 and the Narcotic Control Act of 1961 (p.1116). Both laws are administered under the Health Protection Branch of Health Canada. Enforcement of the Narcotic Control Act is delegated to the RCMP

Nurses responsible for their own actions regardless of whether there is a written order. If physician writes incorrect order, nurse who administers written incorrect dosage is responsible for the error. Under the law, nurses are responsible for their own actions regardless of whether there is a written order. If a physician writes an incorrect order, a nurse who administers the written incorrect dosage is responsible for the error. Therefore, nurses should question any order that appears unreasonable and refuse to give the medication until the order is clarified.

Pharmacokinetics is the study of the absorption, distribution, biotransformation, and excretion of drugs.

Absorption Process by which a drug passes into bloodstream. 1st step in movement of drug through body (Unless drug is administered directly into bloodstream) For absorption to occur, correct form of drug must be given by route intended. Rate of absorption of in stomach variable & depends on: food, acidity of stomach, application of heat or cold. Absorption is the process by which a drug passes into the bloodstream. Unless the drug is administered directly into the bloodstream, absorption is the first step in the movement of the drug through the body. For absorption to occur, the correct form of the drug must be given by the route intended. The rate of absorption of a drug in the stomach is variable and depends on the following factors: food, acidity of stomach, and application of heat or cold.

Distribution The transportation of drug from its site of absorption to site of action. When a drug enters bloodstream, it is carried to most vascular organs – liver, kidneys & brain Body areas with lower blood supply – skin and muscles – receive the drug later. Chemical & physical properties of drug largely determine area of body to which drug will be attracted Distribution is the transportation of a drug from its site of absorption to its site of action. When a drug enters the bloodstream, it is carried to the most vascular organs – liver, kidneys, and brain. Body areas with lower blood supply – skin and muscles – receive the drug later. The chemical & physical properties of a drug largely determine the area of the body to which the drug will be attracted

Biotransformation May be impaired if a person has an unhealthy liver. Called detoxification or metabolism Process = drug is converted to a less active form. Most biotransformation takes place in liver Products of process called metabolites. Types of metabolites: active and inactive. active metabolite has a pharmacological action itself, whereas an inactive metabolite does not. May be impaired if a person has an unhealthy liver. Also called detoxification or metabolism Process by which a drug is converted to a less active form. Most biotransformation takes place in the liver, where many drug-metabolizing enzymes in the cells detoxify the drugs. The products of this process are called metabolites. There are two types of metabolites: active and inactive. An active metabolite has a pharmacological action itself, whereas an inactive metabolite does not. Biotransformation may be impaired if a person has an unhealthy liver. Nurses must be alert to the accumulation of the active drugs in these clients and to subsequent toxicity.

Process by which metabolites & drugs eliminated from body. Excretion Process by which metabolites & drugs eliminated from body. Most eliminated by kidneys in urine some excreted in feces, breath, perspiration, saliva & breast milk. Efficiency of kidneys to excrete drugs and metabolites diminishes with age Excretion is the process by which metabolites and drugs are eliminated from the body. Most metabolites are eliminated by the kidneys in the urine; however some are excreted in the feces, the breath, perspiration, saliva, and breast milk. The efficiency with which the kidneys excrete drugs and metabolites diminishes with age

Effects of drugs The therapeutic effect of a drug, also referred to as desired effect, is primary effect intended, that is the reason the drug was prescribed

Usually predictable & may be either harmless or potentially harmful. Effects of drugs A side effect, or secondary effect, of a drug is one that is unintended. Usually predictable & may be either harmless or potentially harmful. Some tolerated for drug’s therapeutic effect More severe, also called adverse effects, may justify the discontinuation of a drug A side effect, or secondary effect, of a drug is one that is unintended. Side effects are usually predictable and may be either harmless or potentially harmful. Some side effects are tolerated for the drug’s therapeutic effect; more severe side effects, also called adverse effects, may justify the discontinuation of a drug

ingestion of drug intended for external use Drug toxicity (harmful effects of a drug on an organism or tissue) results from overdosage, ingestion of drug intended for external use buildup of drug in blood because of impaired metabolism or excretion. Some toxic effects apparent immediately, some not be apparent for weeks or months. Drug toxicity (harmful effects of a drug on an organism or tissue) results from overdosage, ingestion of a drug intended for external use, and buildup of the drug in the blood because of impaired metabolism or excretion. Some toxic effects are apparent immediately, some not apparent for weeks or months.

A drug allergy is immunologic reaction to a drug. When a client is 1st exposed to foreign substance (antigen), body may react by producing antibodies. Client can react to a drug as to an antigen & develop symptoms of an allergic reaction. Allergic reactions can be mild or severe; from a mild rash to an anaphylactic reaction. Can occur anytime from few minutes to 2 weeks after the administration of drug. A drug allergy is an immunologic reaction to a drug. When a client is first exposed to a foreign substance (antigen), the body may react by producing antibodies. A client can react to a drug as to an antigen and thus develop symptoms of an allergic reaction. Allergic reactions can be mild or severe; from a mild rash to an anaphylactic reaction. It can occur anytime from a few minutes to 2 weeks after the administration of the drug.

Drug tolerance exists in person who has unusually low physiologic activity in response to a drug & who requires increases in dosage to maintain therapeutic effect. Drugs that commonly produce tolerance are opiates, barbiturates, ethyl alcohol tobacco

A drug interaction occurs when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs. Effect of one or both drugs may be either increased or decreased. Drug interactions may be beneficial or harmful

Parenteral (IM, IV, ID sc) Inhalation Rectal Vaginal Routes of administration of drugs: Oral, s.l., buccal Topical Transdermal Parenteral (IM, IV, ID sc) Inhalation Rectal Vaginal Covered in their text on p. 754-6 With table 33-6 outlining summary of the routes of administration

speed of absorption desired site of action of medication The route of administration is chosen according to the speed of absorption desired site of action of medication

Some medications are formulated for a specific route only and must be given in that manner. It is important that medicines be administered as directed by the manufacturer.

Oral too slow if rapid absorption required, Oral and enteral administration require by medication not be destroyed by environment of stomach & digestive enzymes. Oral too slow if rapid absorption required, Cannot be used if patient is vomiting. Rectal administration in form of liquids or suppositories circumvents this problem Oral and enteral administration require the medication not be destroyed the environment of stomach & digestive enzymes. Oral administration is too slow if rapid absorption is required, and cannot be used if patient is vomiting. Rectal administration in form of liquids or suppositories circumvents this problem in enteral administration.

Vaginal or rectal administration also mucosal routes of medication Mucosal routes of administration include absorption through Nasal mucosa Buccal mucosa, Sublingually, Bronchioles (usually achieved through inhalation of an aerosol) Vaginal or rectal administration also mucosal routes of medication iontophoresis = The process of electric current traveling through a salt solution, causing migration of the metal (positive) ion to the negative pole and the radical (negative) ion to the positive pole. 2. The introduction of various ions into tissues through the skin by means of electricity. Copyright 1997 by F.A.Davis Company

Percutaneous administration is most often used by direct absorption through skin

Parenteral administration is used when a drug cannot be given by mouth. speed of absorption varies greatly with the specific route used, which may be subcutaneous, intravenous, intramuscular, intra-arterial, intraperitoneal, intrathecal, intracardiac, or intrasternal. Copyright 1997 by F.A.Davis Company intrathecal = Within the spinal canal. Copyright 1997 by F.A.Davis Company

Factors that influence drug action Developmental factors such as pregnancy and age Gender due to distribution of body fat and fluid and hormonal differences

Factors that influence drug action Cultural, ethnic & genetic factors Genetic factors may contribute to toxic effects because of being unable to eliminate a drug or metabolizing it too fast. The use of herbal remedies may counteract prescribed medications

Factors that influence drug action Nutrients can affect the action of a medication Environment. The client’s exposure to severe physical and emotional stress triggers a hormonal response that eventually may interfere with drug metabolism. Exposure to heat and cold can affect responses to drugs (vasodilation and vasoconstriction)

Factors that influence drug action Psychological factors: a client's expectations about what a drug can do could affect the response to medications Illness and disease can also affect the action of a drug. Drug action is altered in clients with circulatory, liver, or kidney dysfunction

Factors that influence drug action Time of administration of oral medications affects the relative speed with which they act. Orally administered medications are absorbed more quickly on an empty stomach. Thus oral medication given 2 hours prior to meals work faster than those taken after meals.

The Drug order Tylenol 500 mg, ii tabs po qid x 10 days Drug order sheet usually stamped with pt’s addressograph to contain all relevant demographic info of client Orders for drugs usually in this sequence: Drug name Dosage Administration route Time & frequency of administration Tylenol 500 mg, ii tabs po qid x 10 days

Various components of a drug order Full name of client Date and time the order is written Name of the drug to be administered Dosage of the drug Route of administration Frequency of administration Signature of the person writing the order

Example of written prescription in community setting

Types of medication orders stat order single order standing order prn order

Types of medication orders stat order indicates that the medication is to be given immediately and only once Minipress 4mg po stat

Types of medication orders … single order or “one-time order” is for medication to be given once at a specified time Minipress 4mg po @ 1600h today

Types of medication orders … standing order may or may not have a termination date. May be carried out indefinitely until an order is written to cancel it, or may be carried out for a specified number of days Minipress 4mg po q6h Minipress 4 mg po q6h if systolic BP >140

Types of medication orders … prn order, “as needed order,” permits nurse to give a medication when, in the nurse’s judgment, the medication is needed and when it can be safely administered Tylenol 500 mg, ii tabs for pain as required q4h

Dealing with drug orders Once you determine the order contains all the necessary info, you begin to Interpret it (if any info missing or writing is illegible, clarify with doctor before transcribing) Transcribe it to a medication sheet record. (MAR = medication administration record). You will need to initial the order sheet & med record to indicate it was you who correctly transcribed the order Direct a copy to pharmacy for prep of medicine to be delivered to unit

Differentiate between prescribing, dispensing & administering medications. Who is responsible for each of these roles? The physician prescribes medications (unless there is a nurse practitioners act). The pharmacist prepares & distributes prescribed drugs. The pharmacist is responsible for filling prescriptions accurately & for being sure that prescriptions are valid The nurse’s role extends beyond simply giving drugs to a client. >>>>>>>>>>>>>>>>

Nurse’s role The nurse must determine whether a client should receive a drug at a given time assess the client’s ability to self-administer drugs, provide medications at the proper time, monitor the effects of prescribed medications. Client and family education about proper drug administration and monitoring is also the nurse’s role

The “five (plus one) rights” of drug administration Right drug Right dose Right time Right route Right client And… 6.Right documentation

The 3 checks! When the drug is taken from the storage area When preparing to give a med, the label of a drug is checked 3 times When the drug is taken from the storage area Immediately after removing the drug from its container Before returning the container back to its storage area

If the dosage is too high Refusing to give a drug You can legally refuse to administer a drug under these circumstances If the dosage is too high If the drug might interact dangerously with other drugs taken by the patient If the pt’s physical condition contraindicates the drug

Notify your immediate supervisor When you refuse to carry out a drug order you: Notify your immediate supervisor Notify the doctor (if your supervisor has not done so) Document medication not given

Various medication systems Stock supply, unit dose system or computer controlled Stock supply Medications are available in quantity in stock containers. Nurse prepares individual doses from large stock supply container. Time consuming and costly. Narcotics are often provided in stock supply

Various medication systems Unit-dose system Consist of a drawer with 24-hour supply of medications for each client. Is the ordered dose of medication client receives at a prescribed hour. At a designated time each day pharmacist refills the drawers with a fresh supply of individually wrapped medications. This system reduces the number of medication errors saves steps in dispensing drugs

Various medication systems Computer-controlled dispensing systems Are especially useful for the delivery and control of narcotics. Each nurse has a security code that allows access to the unit. The client’s hospital number is then entered. The nurse can select the desired drug, dose, and route. The system delivers the medication to the nurse and records it.

Nurses responsibilities in med administration Regardless of route of administration you will: Obtain MAR or order and verify order Check for allergies Identify the client Inform the client Administer the drug (5 + 1 rights & 3 checks) Provide adjunctive interventions as indicated Record the drug administered Evaluate the client’s response to the drug Kozier, p 764

Variations in the way drugs affect infants, children, and the elderly Usually requires small dosages because of their body size and the immaturity of their organs, especially the liver and kidneys. Dosages often calculated according to weight They often do not have all the enzymes required for drug metabolism and therefore may require different medications than adults.

Variations in the way drugs affect infants, children & elderly Children vary in age, weight, body surface area, and the ability to absorb, metabolize, and excrete medications. Children’s doses are lower than those of adults, so special caution is needed in preparing medications for them. All children require special psychological preparation before receiving mediations.

Variations in the way drugs affect infants, children & elderly Older adults Have different responses to medications due to physiologic changes that accompany aging. Changes include decreased liver and kidney function, which can result in the accumulation of the drug in the body. May be on multiple drugs & incompatibilities may occur. Older adults often experience decreased gastric mobility and decreased gastric acid production and blood flow, which can impair drug absorption. Increased adipose tissue and decreased total body fluid proportionate to body mass can increase the possibility of drug toxicity.

Abbreviations commonly employed in prescription orders See Table 30-3 p.840 and 30-8 p.847 Each facility will have a list of approved abbreviations accepted while charting in that facility.

24-hour clock system eliminates need to specify a.m. or p.m. Time is expressed as a 4-digit number. The first two digits indicate the hour (1230h) Second two digits represent the minute. (1230h)

Minutes are shown from 01 through 59. 24-hour clock The hours are numbered consecutively from 00 through 23, with midnight = 00. Minutes are shown from 01 through 59. The a.m. hours generally keep the same number as in the 24-hour system, while you need to add 12 to the p.m. hours to obtain their 24-hour clock equivalent. Midnight and noon are special cases.

Utilization of the 24-hour clock for administration of medication Converting from am/pm to 24 hour clock: between 12:00 AM and 12:59 AM, subtract 12 hours: 12:59 AM = 0059h between 1:00 AM and 12:59 PM, a straight conversion: 10:00 AM = 1000h between 1:00 PM and 11:59 PM, add 12 hours: 10:59 PM = 2259h Midnight = 2400h 1 min after midnight = 0001h

Times & med admin q6h is not the same as qid q8h is not the same as tid