1. Medication Administration
Unit VI
Part 2 (lecture)
Keith Rischer, RN, MA, CEN, CCRN

2. Today’s Objectives…
Differentiate the various effects of drugs on the body
Explain how age, illness, time of administration, & absorption affect drug action
Describe the relationship between mechanism of action of most commonly used drugs and nursing assessment and implications for the nurse

3. Minnesota Nurse Practice Act
Legal aspects r/t the nurse
(6) Engaging in unprofessional conduct, including, but not limited to, a departure from or failure to conform to board rules of professional or practical nursing practice … to the minimal standards of acceptable and prevailing professional or practical nursing practice, or any nursing practice that may create unnecessary danger to a patient's life, health, or safety. Actual injury to a patient need not be established under this clause.
The Nurse Practice Act – defines the scope of practice, professional functions and responsibilities of nurses in their various roles. Purpose is to protect the public from unskilled, undereducated, and unlicensed personnel.
Nurses should understand legal aspects of health care, pharmacology, pharmacokinetics, life sciences, human anatomy, and MATH.. Therefore, Knowledge and skill is vital.
Accountable = responsible for one’s actions.
Practice of professional nursing.
The "practice of professional nursing" means the performance for compensation or personal profit of the professional interpersonal service of: (1) providing a nursing assessment of the actual or potential health needs of individuals, families, or communities; (2) providing nursing care supportive to or restorative of life by functions such as skilled ministration of nursing care, supervising and teaching nursing personnel, health teaching and counseling, case finding, and referral to other health resources; and (3) evaluating these actions. The practice of professional nursing includes both independent nursing functions and delegated medical functions which may be performed in collaboration with other health team members, or may be delegated by the professional nurse to other nursing personnel. Independent nursing function may also be performed autonomously. The practice of professional nursing requires that level of special education, knowledge, and skill ordinarily expected of an individual who has completed an approved professional nursing education program as described in section , subdivision

4. Laws and Regulations Drug legislation in the U.S.
Pure Food and Drug Act
Harrison Narcotic law of 1914 – defined narcotic
Federal Food, Drug and Cosmetics Act of 1938 established the FDA, set standards r/t safety, potency, efficacy.
Durkham-Humphrey Amendment of 1952 differentiates between prescription and non-prescription drugs.
Federal regulations – protect people by ensuring that the pharmaceutical companies produce medications that are safe and effective.
The first law regulating medications was the Pure food and Drug Act (1906). – it required that medications be free of impurities
Subsequent legislation lead to specified standards for medication labeling and established the FDA and official standards (USP) and National Formulary United States Pharmacopeia and national formulary are official publications which set standards for medication strength quality, purity, packaging, safety, labeling, and dose form..
Chart in book pg 687 – tracts the time line of medication laws and their provisions.
The FDA (food and drug administration) enforces medication laws and ensures that medications on the market have undergone specific and rigorous testing before sold to the general public
FDA – follows medication law in the control of medication sales and distribution, testing, naming, labeling and the regulation of controlled substances.
States often establish further controls. Local government bodies regulate alcohol and tobacco.
Further still, the health care institutions establish their own policies to meet federal, state and local laws.

5. Laws and Regulations Controlled Substance Act 1970
Categorizes controlled substances
Limits refills
Established programs to prevent and treat drug dependence
FDA instituted the MedWatch program in 1993
This act (law) was enacted to control the distribution and use of all depressants, stimulant drugs and other drugs of abuse of potential abuse as designated by the Drug Enforcement Administration of the Department of Justice.
Controlled substances=
The nurse is required to follow specific guidelines– defined by federal and statewhen administering controlled substances.
Violations are severe.
FDA instituted - Med Watch program encourages health professionals to report when a drug causes serious harm to the client. It is voluntary
Its primary purpose is to get to the bottom of what went wrong – how it can be fixed.

6. Consumer Rights Drugs are safe, pure, effective and reliable
Clients have the right to quality health information r/t drugs and medications
Name, of drug, purpose, action, possible adverse side effects.
FDA = Food and Drug Administration – is authorized to supervise the production of meds to ensure safety for people. It is the consumers right to be provided with drugs that are safe, pure, effective and reliable.
Patient Care Partnership is the AHA's Patients' Bill of Rights, this plain language brochure informs patients about what they should expect during their hospital stay with regard to their rights and responsibilities. Available is several languages. States Pt rights, expectations and responsibilities
Regarding meds : pt’s have a right to information about drugs before they receive them. The right to know the name, purpose, action, possible adverse or side effects.

7. Consumer Rights Patients have a right to: To refuse any medications
To have qualified person assess medication history including allergies
Not to be given unnecessary medications
Read Above
Also: advised properly if meds are a part of research or of an experimental nature. Receive meds in accordance with 6 rights.

8. Safety The Joint Commission
Oxycontin vs. Oxycodone
Hydromorphone vs. Morphine
Ephedrine vs. Epinephrine
Hydralazine vs. Hydroxyzine
ISMP Institute for Safe Medication Practices
– JOINT COMMISION publishes a look-alike/sound alike drug list and recommendations for nurses, prescribers and other health care organizations to prevent medication mix up.
Joint Commission accreditation is focused on patient safety and better quality outcomes. Previously, we thought of it more as a necessary hurdle. Now, we view accreditation as an integral part of our continuous readiness efforts to drive sustained improvement.
The ISMP is a non profit healthcare agency comprised of pharmacists, nurses, physicians Founded in 1994 dedicated to learning about medication errors, understanding their system-based causes and disseminating practical recommendations that can help healthcare providers, consumers, and the pharmaceutical industry prevent errors.
They are not governmental or regulatory but work in collaboration with those that are.
Talk about ISMP
Go to web page to view abbreviations, Tall Man letters, Look alike and sound alike meds

9. Schedule of Controlled Substances
Schedule I: High potential for abuse
No medical use exists
Heroin
Schedule II: Potential for abuse, physical and psychological dependence
Has accepted medical use
No refills
Methadone, Morphine, Fentanyl, Oxycontin, Percocet
The schedule of controlled substances refers to the level of control. (whether it requires a prescription from a doctor or other prescriber). Prescribers are regulated as to what level (or schedule) they are authorized to prescribe.
Centrally acting drugs like narcotics, stimulants, sedatives are divided into 5 schedules: Controlled substances are labels with a large C
SCHEDULE I.
(A) The drug or other substance has a high potential for abuse.
(B) The drug or other substance has no currently accepted medical use in
treatment in the United States.
(C) There is a lack of accepted safety for use of the drug or other substance under
medical supervision.
2. SCHEDULE II.
(B) The drug or other substance has a currently accepted medical use in treatment
in the United States or a currently accepted medical use with severe restrictions.
(C) Abuse of the drug or other substances may lead to severe psychological or
physical dependence.

10. Schedule of Controlled Substances
Schedule III: intermediate potential for abuse
Has accepted medical use
May Refill 5 times
Vicodin, Tyl. #3
Schedule IV: Less abuse potential.
May refill 6 times within 6 months
Benzodiazepines, Ambien
Schedule V: Minimal abuse potential
Cough suppressants with codeine
Schedule III – some potential for abuse – refill 5 times – this may include drugs such as codeine in combonation with other drugs. ( tylenol #3)
Schedule IV include sedatives and sleeping pills.
Schedule V – has minimal abuse potential.
SCHEDULE III.
(A) The drug or other substance has a potential for abuse less than the drugs or
other substances in schedules I and II.
(B) The drug or other substance has a currently accepted medical use in treatment
in the United States.
(C) Abuse of the drug or other substance may lead to moderate or low physical
dependence or high psychological dependence.
4. SCHEDULE IV.
(A) The drug or other substance has a low potential for abuse relative to the drugs
or other substances in schedule III.
(C) Abuse of the drug or other substance may lead to limited physical dependence
or psychological dependence relative to the drugs or other substances in schedule
III.
5. SCHEDULE V.
or other substances in schedule IV.

11. Controlled Substances
Drugs kept in locked drawer
Forms for recording the use of these drugs
Nurse verifies the number of a specific drug available
If drug wasted, second nurse acts as a witness
Drugs are counted each shift with 2 RNs
Read this
How are controlled substances handled in the health care setting?
Drugs are kept under lock in a med cart, or in pyxis locked electronically.
On medication carts such as you find in skilled nursing facilities, there is a narcotic book where documentaion is kept and updated every 24 hours
Student nurse can not verify drug count with RN.
Frugs aare wasted with another nurse as a witness/ and signed for by both.
Drugs are counted regularly. With 2 RNs per institution policy.

12. Pharmacokenetics Study of action of drugs within the body Absorption
Must consider before administering meds
Absorption
Distribution
Metabolism
Excretion
Pharmacokenetics is a study of how the medication enters the body, reaches the site of action, is metabolized and is excreted from the body
It describes how the drug is absorbed, how it gets to its target site, how it is metabolized and then how it is excreted.

13. Pharmacokenetics: Absorption
Process by which drug passes into the bloodstream
better the blood supply faster the absorption
GI tract: variable
IV: immediate
Subcutaneous: depends on local blood flow
Intramuscular: depends on local blood flow
Topical: slow, incomplete
Inhalation: rapid
Rectal: may be erratic
Absorption: refers to how the medication enters the body and gets into the blood stream. This process is influenced by the route of administration(oral, parenteral, topical etc)
Explain above routes
GI – usually slow, depending on food in the GI tract, acidity,(acidic meds pass through quicker, basic are absorbed in the small intesting, integrity of the gastric mucosa.
IV – immediate
Sub Q– dependant on the local blood flow, adiposity of the tissue, local conditions of the injection site, exercise
IM – same as subQ
Topical – usually slow and variable as to the percentage of med that is absorbed.
Inhaled – usually fast due to the large numbers of blood vessels in the lung tissue.
Rectal – very erratic, unpredictable.

14. Pharmacokenetics: Absorption
Factors influencing absorption
Dose form and route
Influence of pH
Blood flow to site
Solubility of drug
Time Action Profile
Onset
Peak
Duration
Other factors that influence absorption…in addition to the route ( oral, parenteral, topical etc), absorption is influence by the ability of the medication to dissolve, the blood flow to the area, body surface (like small intestines), lipid solubility of the medication(cell membranes have a lipid layer – so meds that are highly lipid soluable are absorbed quickly. Absorption is also affected by food in the stomach and if given with other medications which may interfere with each other.
Absorption is affected by route and dose and by Ph of the environment.

15. Pharmacokenetics: Distribution
Transportation of drug from site of absorption to site of action.
Vascular organs receive drug first, then skin and muscles.
Chemical/physical make up of the drug determines to which area of body drug will be attracted.
Distribution: this refers to the way the medication moves to the site of action in the body. This becomes important in choosing one drug over another. Distribution affected by circulation (vascularity), membrane permeability, protein binding factors.
Fat soluble drugs accumulate in fatty tissue, others bind with plasma proteins. The brain only allows fat soluble medications through. The geriatric patient has less albumin ( protein) and therefore more of the free medication is available to exert a pharmacological effect on the individual.
The physical and chemical make up of the drug influences which area of the body the drug will be attracted to. The physiology of the person also influences this process.
For example: the distribution of a medication will influence the decision to avoid a drug. for example with holding a medication that crosses the placenta or can get into breast milk.

16. Pharmacokenetics: Metabolism
The process of altering or changing the drug into a less active form.
Caution: this process may be impaired in the elderly or in someone with liver disease
Biotransformation
Metabolism: This is the process where chemical reaction occurs which breaks down the medication until it is no longer active. This occurs primarily in the liver but can occur in the kidney, lungs, intestines or blood. In cases where the liver is not functioning optimally, such as in disease and in the aging, the medication lingers and can reach levels of toxicity in the body. Biotransformation = the transformation of medication (breakdown) under the influence of enzymes

17. Pharmacokenetics: Excretion
Process by which drug is eliminated from the body.
Caution: since the kidneys/liver of older adults are less efficient, they may require smaller doses of a drug.
Promote adequate fluid intake
Excretion: This is the process that the medication, now metabolized, is eliminated from the body…occurs via the GI tract, kidneys, and other body secretions. Kidneys are the main organs for medication excretion.The chemical makeup of medications = determines organ of excretion.
Maintenance of fluid intake of 50mL/kg/day promotes proper medication elimination. (not just water)
A decreased kidney function – requires a decrease in dose of medication.
Example: How many mL should a person weighing 132 lb take in each day to promote proper medication elimination?
132/2.2 = 60 kG
50x60 = 3,000 mL

18. Medication Pharmokinetics
Morphine
Tylenol
Ibuprofen
Atenolol
Coumadin
Why is pharmokinetics relevant if your patient has renal or liver disease?
If pt. has kidney/liver disease know excretion and note on drug card
Morphine…metabolized by liver…excreted renal
Tylenol…same as above
Ibuprofen…absorbed well po…same as above
Atenolol…50-60% absorbed po…excreted by kidneys
Coumadin…well absorbed po…metabolized by liver

19. Special Dosing Considerations
Renal Disease
Chronic renal insufficiency
Diabetes
CKD-dialysis dependant
Labs
GFR
Creatinine
KIDNEYS PRIMARY ORGAN OF EXCRETION/ELIMINATION
Will need smaller doses to have same effect.
Watch for adverse effects/toxicity

20. Special Dosing Considerations
Liver Disease
Cirrhosis
Hepatitis
ETOH
Labs
AST
ALT
Bili
Albumin
LIVER PRIMARY ORGAN OF METABOLISM
Changes drug from fat soluable to water soluable to be excreted by kidneys
Jaundice or low albumin will have difficulty metabolizing drugs

21. Special Dosing Considerations
Heart failure
CHF
Diastolic
Systolic
Cardiomyopathy
Body size
Underweight/pediatric
calculated by weight or body surface area
Obese
Normal
There is a certain expectation for a response to drugs of the average individual…However.if the patient was underweight or overweight, the response could be different.

22. Developmental Factors/drug action
Pregnancy
Infants
Older adults
Diet
Food alters drug absorption rate, metabolism
Nutrition can affect the action of a drug
Ex: Vitamin K – found in green leafy vegetables can counteract the effect of an anticoagulant – Coumadin
Certain developmental factors affect drug action:
Pregnancy: greatest risk for fetus is the first 3 months of gestation when vital organs and functions of the fetus are being formed.
Infants: smaller doses due to body size and immaturity of organs (such as liver and kidneys)
Older adults: decrease in liver and kidney function can increase drug accumulations. A decrease in gastric acid production, and blood flow can impair drug absorption, increased toxicity can occur cue to increase in body fat, less body fluid. A change in the blood-brain barrier which allows fat soluble drugs to pass more readily, can cause confusion and dizziness ( Ex: with beta blockers) Also in the case of polypharmacy, incompatibilities may occur.
LESS COMPLETE AND SLOWER ABSORPTION FROM GI TRACT…DECREASED GASTRIC MOTILITY
Food in the stomach alters the rate of absorption and completeness of absorption in any individual. Absorption is also affected by metabolism – (sum of alll physical and chemical changes that take place within an organism
Some Food properties affect action of a drug.
EX: Vitamin K is an essential player in the coagulability of blood. It is needed for the synthesis of clotting factors
Grapefruit and related citrus fruits can inhibit the isoenzymes in the intestine which inihibits the pre systematic breakdown of the drug. Therefore more of the drug gets into the system and can cause an increased thereapeutic effect ( amiodarone (heart med) and lipitor are a couple of examples you will see more often) In some cases Grafefruit is known to cause a decreased efficacy of certain drugs..

23. Factors affecting drug action: Elderly
Use w/caution
Digoxin
Nifedipine
Benzodiazepines
Alprazolam
Diazepam
Increased fall risk
ACE inhibitors
Beta blockers
Ca++ channel blockers
Vasodilators
Diuretics
Opiod narcotics
Anti-depressants
Benzodiazepines

24. Factors affecting drug action
Environmental
Time of administration
Stress
Exposure to heat and cold
Cultural, ethnic, genetic
Ethnopharmacy
Cultural factors and practices
A patients environment can affect the action of drugs, particularly those used to alter behavior and mood.. Nurses need to consider the effects of a drug in the context of the client’s personality and surroundings.
From a practical point of view: If the temp is high, this causes vasodilitation of peripheral blood vessels, which can intensify the action of vasodilators. And vise versa in cold environments.. If a client took an analgesic or sedative in a noisy environment vs a quiet environment, it is likely to have a different effect.
Cultural ethnic and genetic factors are getting more attention:
in 2004 a new genetic blood test –was developed which analyses genes in a clients blood for differences that could cause the variations in metabolism of certain drugs.
Ethnopharmacy – NEW – it is the study of the effect of ethnicity on responses of prescribed medications. Research shows that certain medications may work well at usual therapeutic dosages for certain ethnic groups but be toxic for others..
EX; African Americans respond differently to psychotropic drugs (anti depressants)- have a quicker response, higher blood levels, and more adverse effects than Caucasians. – may require lower doses
Also respond differently to antihypertensives – Ace inhibitors – and angiotensen II receptor antagonists – are less effective and others such as (HCTZ ) are more effective
Beta blockers( antihypertensive) – AA may require more and Asians may require less.

25. Mechanism…Nursing Implications
Analgesics
Morphine, Dilaudid, Percocet, Vicodin
Mechanism:
Binds to opiate receptors in CNS
Produces generalized CNS depression
Opiate effects cause vasodilation, decreased peristalsis
Nsg. Implications…
NSG IMPLICATIONS
Assess LOC
Assess BP-pulse and resp
Assess for constipation…increase fluids-give stool softerners
SE,,,confusion, sedation, resp depression, hypotension, constipation 25

26. Classifications/Nursing Implications
Analgesics
Mild
Tylenol
NSAIDS
Ibuprofen, Aspirin
Moderate-
Opiod Narcotics po
Tylenol #3, Vicodin, Percocet
Severe-
Opiod Narcotics IV
Morphine, Dilaudid, Fentanyl
Classification of a drug places a medication into a class of drugs that have a certain effect of the body
There are usually more than one (several) of different medications that are used to achieve a similar effect.
A therapeutic classification classifies the drug into the disease state they are used to treat. The pharmacologic classification is based on the mechanism of action.
In our drug book there is a section at the front of the book which separates the drugs into major therapeutic classifications. Many times medications in each class share similar mechanisms of action, assessment guidelines, precautions, and interactions. This list also includes teaching points for that class and a list of drugs with page numbers within each class.
A single medication can fall into more that one classification:
Ex: Aspirin is an analgesic, anti inflammatory, and anti pyretic, anticoagulant
Nursing Implications
Analgesics…max dose of tylenol…give NDAIDS w/food…Narcs assess BP, LOC before and after …know time action profile
Antibiotics…assess allergic response…obtain blood cultures before first dose 26 26

27. Anticoagulants Warfarin (Coumadin) Heparin Aspirin Mech of Action Uses
Nursing implications
Vitamin K clotting factors
INR ( )…11-13 seconds clotting time
2-3 therapeutic
Heparin
Mech of action
Prevents conversion of fibrinogen to fibrin
Aspirin

28. Mechanism…Nursing Implications
Calcium Channel Blockers
Diltiazem
Mechanism:
Inhibits transport of calcium into myocardial and vascular smooth muscle cells during the cardiac action potential phase.
Causes systemic vasodilation and coronary artery vasodilation as well as slowing AV node conduction and decreased cardiac contractility
Nsg. Implications…
NSG IMPLICATIONS
ASSESS and monitor HR and BP before and after giving
Monitor closely in CHF
CHF most serious SE

29. Mechanism…Nursing Implications
Angiotensin Converting Enzyme (ACE) Inhibitors
Lisinopril, Enalapril
Mechanism:
Blocks the conversion of angiotensin I to vasoconstrictor angiotensin II.
Net effect: systemic vasodilation
Nsg. Implications…
NSG IMPLICATIONS
Lowering of BP
Monitor and assess BP
Excreted by kidneys…may increase creatinine

30. Classifications/Nursing Implications
Loop Diuretics
Furosemide (Lasix)
Mechanism:
Inhibits the reapsorption of sodium and chloride from the loop of Henle and distal renal tubule
Increases renal excretion of water, Na+, Cl-, Mg+, and K+ causing loss of excess fluid and drop in BP
Nsg. Implications…
NSG IMPLICATIONS
Assess fluid status, monitor daily weights and I&O closely
Assess for response and excess fluid depletion
Monitor BP…increased risk of falls with elderly
Assess for signs of hypokalemia and treat as needed
MOST COMMON SE…dehydration, low K+, Cl, Mg, Na

31. Medication interactions
When one medication modifies the action of another, this can occur
Synergistic effect: effect of 2 drugs when combined is greater than when meds given separately.
Beneficial: give Tylenol with oxycodone to reduce the total amount of narcotic needed.(additive effect)
Harmful: Alcohol taken with antihistamines, antidepressants, barbiturates and narcotic analgesics
When 2 (or more) drugs are given together and one modifies the action of the other.
The effect of one or both drugs may be either increased (called potentiating effect) or decreased (inhibiting effect).
Synergistic effect: When two different drugs are given together and one increases the action of the other. EX: when two B/P meds are given to control blood pressure: Such as a diuretic and a vasodilator.
Beneficial: Tylenol #3 (Acetaminophen with codeine) Used to reduce the total amt of narcotic needed.
It has an additive effect
harmful: Alcohol taken with antihistamines, antidepressants, barbiturates, narcotics = potentiate or increase the effect. –
Barbiturates (derived from phenobarbitol): are CNS depressants – tranaquilizing, hypnotic, anti seizure effect
Narcotic: Derived from opium, or opium derivatives which have potent analgesic effects associated with both significant alteration of mood and behavior and with potential for dependence and tolerance.

32. Medication interactions
Iatrogenic disease: disease caused unintentionally by medical therapy
Ex: liver failure after prolonged use of Tylenol
Amiodarone and pulmonary fibrosis
Pregnant woman takes medication that results in malformations in the fetus.
Iatrogenic disease – a broad term that includes the unintentional effect of some medications(drugs)
Another example : Liver failure causes by extensive use of acetaminophen…max is 4000mg daily

33. Nursing implications
What can nursing do to enhance desired effect/decrease adverse effects and ensure safety??
History
Allergies
Shellfish…Iodine
Med data
Clients condition
Clients knowledge/learning needs
The answer is plenty!!!
History – provides nurse with general knowledge of types of meds pt is on. Also any potential adverse medication effects, contraindications/indications. Long term illness require special considerations. AGE also.
Allergies – HUGE consideration both allergies to medications and foods. Some foods contain substances that are in medications. Your book sites a good example of pt’s allergic to shellfish may be sensitive to any medication containing iodine (such as tests requiring radioactive dye)
Medication data: Knowledge of how long the pt has taken the medication, dosage, any adverse effects from the med, action, purpose route side effects and nursing implication for administering and monitoring will guide the nurse to obtain certain data prior to administering the medication.
Included in this assessment is the completion of a medication reconciliation – which is a required part of a patient admission procedure in most institutions.
This is a purposeful comparison of client’s medications (at home or another facility) with the doctor’s admitting medication orders. This action occurs on admission and at discharge.
Assess the Clients’ current condition: Such as V/S, I&O, certain lab values Labs. Also assess any contraindications for oral meds such as Inability to swallow, N&V, Bowel inflammation
Decreased peristalsis, GI surgery, gastric suction
Client knowledge: will direct pt education sessions and provide information regarding pt compliance.

34. Drug Medication Systems
Stock Supply
Unit-Dose
Automated Medication Dispensing (Pyxis)
Bar Code Medication – use of scanner
Self-administered
PCA, Inhalers, ointments etc
Drugs are dispensed in several ways\
Stock supply – on the floor in bulk
Unit dose – packaged individually or on cards to be used over days.
Pyxis in an automated medication dispensing system – much used today for both regular medications and controlled substances.
Bar Code medication – a scanner is used both on the med and on the pt;’s arm band to match med with patient
Self administered. – such as PCA, inhalers, creams, ointments, OTC meds.