Canadian Fundamentals of Nursing - Revised Reprint,...

Canadian Fundamentals of Nursing - Revised Reprint, 4th Edition

34 Medication Administration

Written by

Jill E. Vihos, RN, BScN, MN, PhD(c)

Based on the original chapter by

Sheryl Buckner, RN-BC, MS, CNE

objectives

Mastery of content in this chapter will enable you to:

▪ Define the key terms listed.

▪ Examine the nurse's role and responsibilities regarding medication administration.

▪ Describe the physiological mechanisms of medication action, including absorption, distribution, metabolism, and excretion of medications.

▪ Differentiate among different types of medication actions.

▪ Discuss developmental factors that influence pharmacokinetics.

▪ Discuss factors that influence medication actions.

▪ Discuss methods of educating a client about prescribed medications.

▪ Compare and contrast the roles of the prescriber, the pharmacist, and the nurse in medication administration.

▪ Implement nursing actions to prevent medication errors.

▪ Describe factors to consider when choosing routes of medication administration.

▪ Calculate a prescribed medication dose.

▪ Discuss factors to use when assessing a client's needs for and response to medication therapy.

▪ Explain the seven rights of medication administration.

▪ Prepare and administer subcutaneous, intramuscular, and intradermal injections; intravenous medications; hypodermoclysis infusions; oral and topical skin preparations; eye, ear, and nose drops; vaginal instillations; rectal suppositories; and inhalants.

▪ Describe the importance of safe medication techniques.

▪ Describe the importance of establishing and adhering to agency policies and procedures when administering medications.

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▪ Identify and describe how principles of primary health care are applied to medication administration in nursing practice.

key terms

Absorption, p. 678

Adverse effects, p. 680

Anaphylactic reactions, p. 680

Biotransformation, p. 679

Buccal, p. 683

Concentration, p. 681

Controlled substances, p. 678

Culture of safety, p. 691

Detoxify, p. 679

Hypodermoclysis, p. 748

Idiosyncratic reaction, p. 680

Infusions, p. 681

Inhalation, p. 684

Injection, p. 679

Instillation, p. 684

Intra-articular, p. 683

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Intracardiac, p. 683

Intradermal (ID), p. 683

Intramuscular (IM), p. 683

Intraocular, p. 684

Intravenous (IV), p. 683

Irrigations, p. 684

Medication allergy, p. 680

Medication error, p. 690

Medication interaction, p. 680

Medication reconciliation, p. 691

Metered-dose inhalers (MDIs), p. 716

Metric system, p. 684

Narcotics, p. 678

Ophthalmic, p. 708

Parenteral administration, p. 683

Peak concentration, p. 681

Pharmacokinetics, p. 678

Polypharmacy, p. 701



Prescription, p. 687

Serum half-life, p. 681

Side effects, p. 680

Solution, p. 684

Subcutaneous, p. 683

Sublingual, p. 683

Synergistic effect, p. 680

Therapeutic effect, p. 680

Toxic effects, p. 680

Transdermal disc, p. 684

Verbal order, p. 687

Z-track method, p. 738

Clients who have acute or chronic diseases or conditions use a variety of strategies to restore or maintain their health. A medication is a substance used in the prevention, diagnosis, relief, treatment, or cure of health alterations. Medications are the primary treatment that clients associate with restoration of health. No matter where clients receive their health care—;in hospitals, at clinics, or at home—nurses play an essential role in preparing and administering medications, teaching clients about medications, and evaluating clients' responses to medications.

In the primary health care setting, clients often self-administer their medications. As a nurse, you are responsible for evaluating the effects of the medications on the client's health status, teaching clients about their medications and their side effects, ensuring client compliance with the medication regimen, and evaluating the client's technique for all routes of medication delivery. Additionally, you must assess the relationship between a client's medication regime and socioenvironmental influences, including accessibility to resources (e.g., financial and geographical). Consistent with principles of primary health care, nurses can implement interventions to address barriers to effective medication management.

In both acute and restorative health care settings, nurses spend a great deal of time administering medications to clients and ensuring that clients are adequately prepared to self-administer medications when they are discharged. If


Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionclients cannot administer their own medications when they are at home, family members or support persons can take responsibility for this task. As a nurse, you assess the effect of the medications in restoring or maintaining health and continue to educate the client, the client's family, and home care personnel about the medication's purpose, regimen, and side effects.

Scientific Knowledge Base

Medications are administered to clients to prevent, diagnose, or treat disease and health conditions. Because medication administration and evaluation are essential to nursing practice, you need to understand the actions and effects of the medications your clients take. To safely and accurately administer medications, you must have an understanding of pharmacology, pharmacokinetics (the study of how medications enter, affect, and exit the body), human growth and development, human anatomy, pathophysiology, psychology, nutrition, and mathematics. You need to apply your cumulative nursing knowledge when administering medications. The nursing process provides the framework for you to organize your thoughts and actions, and it is the foundation for medication administration.

Pharmacological Concepts

Drug Names.

A medication may have as many as three different names. A medication's chemical name provides an exact description of the medication's composition and molecular structure. Chemical names are rarely used in clinical practice. For example, the chemical name N-acetyl-para-aminophenol is commonly known as Tylenol. The generic, or nonproprietary, name is given by the manufacturer that first develops the medication. Acetaminophen is the generic name for Tylenol. The generic name becomes the official name under which the medication is listed in official publications, such as the Compendium of Pharmaceuticals and Specialties (CPS), the Canadian Formulary (CF), or the United States Pharmacopeia (USP). In addition to the drug name, all drug products approved for distribution in Canada have an eight-digit number, which is assigned by the Health Protection Branch of the federal government. This Drug Identification Number (DIN) is used by various groups and agencies to track drug information across Canada.

The trade name, brand name, or proprietary name is the name under which a manufacturer markets a medication. The trade name is followed by the symbol ™, which indicates that the manufacturer has trademarked the medication's name (e.g., Tempra™, Motrin™). Manufacturers choose trade names that are easy to pronounce, spell, and remember so that laypersons will remember the medication names. A medication may be produced by many different companies, and similarities in their trade names can be confusing. Because similarities in drug names are a common cause of medical errors, the Joint Commission (2007) in the United States publishes on its Web site a list of drugs whose names look like or sound like other drug names as well as recommendations for nurses, prescribers, other health care professionals, and health care organizations to prevent drug errors related to look-alike and sound-alike names of medications. Medications are available under a variety of different nomenclatures, or names, and you must be careful to obtain the exact name and spelling for the particular medications you administer.

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Classification.

Medication classification indicates the effect of the medication on a body system, the symptoms the medication relieves, or the medication's desired effect. For example, clients who have type 2 diabetes often take medications to control their blood glucose level. Sulfonylureas are one classification of medications often used by these clients. At least seven different medications are included in the sulfonylurea classification (McKenry et al., 2006). A prescriber chooses a particular medication on the basis of the client's characteristics; the medication's cost, efficacy, and dosing frequency; and the prescriber's experience with the medication. Some medications belong to more than one class. For example, aspirin is an analgesic, an antipyretic, and an anti-inflammatory medication.

Medication Forms.

Medications are available in a variety of forms, or preparations (Figure 34-1). The form of the medication determines its route of administration. The composition of a medication is designed to enhance its absorption and metabolism. Many medications are made in several forms, such as tablets, capsules, elixirs, and suppositories. When administering a medication, you must be certain to use the proper form (Table 34-1).

Medication Legislation and Standards

Canadian Drug Legislation.

Regulation of drug standards began in Canada in 1884, when the Adulteration Act set the conditions under

Figure 34-1 Forms of oral medications. Top row: Uniquely shaped tablet, capsule, scored tablet. Bottom row: Gelatin-coated liquid, extended-release capsule, enteric-coated tablet.

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionwhich a drug could be adulterated. The Food and Drugs Act of 1920 replaced this Act and, with amendments in 1950, gave the federal government control of the manufacture and sale of all drugs (except narcotics), all food, all cosmetics, and certain medical devices.

The federal government first attempted to control narcotic substances in 1908 through the Opium Act. Cocaine and morphine came under the jurisdiction of this Act in 1911. In 1961, the Narcotic Control Act, which controls the manufacture, distribution, and sale of narcotic drugs, was enacted. This Act was repealed in 1996 and replaced by the Controlled Drugs and Substances Act. The federal government has also passed legislation that regulates the manufacture and sale of herbs and other natural health products. This legislation addresses the content of these products as well as the products' packaging, labelling, distribution, and storage.

Drug Standards.

Official publications, such as the British Pharmacopoeia (BP) and the Canadian Formulary, set standards for drug strength, quality, purity, packaging, safety, labelling, and dosage form. Physicians, nurses, and pharmacists depend on these standards to ensure that clients receive pure drugs in safe and effective dosages. Accepted standards must be met in the following areas:

• Purity: Manufacturers must meet purity standards for the type and concentration of substances allowed in drug products.

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TABLE 34-1 Forms of Medication

Form DescriptionMedication Forms Commonly Prepared for Administration by Oral RouteSolid FormsCaplet Shaped like a capsule and coated for ease of swallowing.Capsule Medication encased in a gelatin shell.Tablet Powdered medication compressed into a hard disc or cylinder; in addition to primary medication,

contains binders (adhesives that allow the powder to stick together), disintegrators (to promote tablet dissolution), lubricants (for ease of manufacturing), and fillers (to make a convenient size for swallowing).

Enteric-coated tablet

Coated tablet that does not dissolve in stomach; coatings dissolve in intestine, where medication is absorbed.

Pill Contains one or more medications; shaped into globules, ovoids, or oblongs; rarely used because most pills have been replaced by tablets.

Liquid FormsElixir Clear fluid containing medication and either water or alcohol, or both; often sweetened.Extract Syrup or dried form of pharmacologically active medication, usually made by evaporating the

solution.Aqueous solution

Medication dissolved in water.

Aqueous suspension

Finely divided drug particles dispersed in a liquid medium; when the suspension is left standing, particles settle to the bottom of the container.

Syrup Medication dissolved in a concentrated sugar solution.Tincture Medicinal alcoholic extract from a plant or vegetable.Other Oral Forms and Terms Associated With Oral PreparationsTroche (lozenge)

Flat, round tablet that dissolves in the mouth to release medication; not intended for ingestion.

Aerosol Aqueous medication sprayed and absorbed in the mouth and upper airway; not intended for ingestion.

Sustained release

Tablet or capsule that contains small particles of a medication coated with material that requires time to dissolve.

Medication Forms Commonly Prepared for Administration by Topical RouteOintment (salve or cream)

Semisolid, externally applied preparation, usually containing one or more medications.

Liniment Preparation that usually contains medication and alcohol, oil, or soapy emollient; applied to the skin.

Lotion Liquid suspension that usually protects, cools, or cleanses skin and can contain medication.Paste Thick ointment; absorbed through the skin more slowly than ointment; often used for skin

protection.Transdermal disc or patch

A disc or patch from which medication is absorbed through the skin slowly over a long period of time (e.g., 24 hours, 1 week).

Medication Forms Commonly Prepared for Administration by Parenteral RouteSolution Sterile preparation that contains water with one or more dissolved medicinal compounds.Powder Sterile particles of medication that are dissolved in a sterile liquid (e.g., water or normal saline)

before administration.Medication Forms Commonly Prepared for Instillation Into Body CavitiesSolution Medication dissolved in water or other liquid.Intraocular disc

Small, flexible oval (similar to a contact lens) consisting of two soft, outer layers and a middle layer containing medication; slowly releases medication when moistened by ocular fluid.

Suppository Solid medicine dosage mixed with gelatin and shaped into a pellet for insertion into a body cavity (rectum or vagina); melts at body temperature to release medication.



• Potency: The concentration of the active drug in the preparation affects its strength, or potency.

• Bioavailability: The ability of a drug to be released from its dosage form and to be dissolved, absorbed, and transported by the body to the drug's site of action.

• Efficacy: Detailed laboratory studies help determine a drug's effectiveness.

• Safety: All drugs need to be continually evaluated to determine their side effects.

Control.

Administration of the Food and Drugs Act and the Controlled Drugs and Substances Act is carried out by the Health Protection Branch (HPB) of the federal government. Before a new drug can be marketed in Canada, an application for approval must be made to the HPB. After intensive testing to ensure the drug's effectiveness and safety in humans, the HPB reviews the application. The HPB issues a Drug Identification Number and Notification of Compliance, which allow the drug to be sold in Canada. Stringent controls are applied to this new drug until sufficient information has been accumulated to ensure its safety and efficacy. Only then is the drug released for general use. Monitoring of the drug is ongoing to report adverse effects, safety concerns, or changes in the indications for a particular drug's use.

Provincial, Territorial, and Local Regulation of Medication.

The provincial and territorial governments do not directly regulate the manufacture or sale of drugs. However, because the provincial and territorial governments have most of the legislative responsibility for health care, provincial and territorial legislation indirectly affects the use and sale of drugs within provincial and territorial boundaries. In addition, each province and territory has legislation regarding medical, dental, pharmacy, and nursing practice that dictates each health care professional's role in the ordering, dispensing, and administration of drugs. In particular, some provincial and territorial pharmacy legislation includes schedules that indicate the drugs that can be sold without prescription, behind the counter, and by prescription only. The National Association of Pharmacy Regulatory Authorities facilitates the activities of the regulatory authorities of all provinces and Yukon and promotes the harmonization of the practice of drug sales across the country.

Health care institutions establish policies that conform to federal and provincial regulations. The size of an institution, the types of services it provides, and the types of professional personnel it employs influence an institution's policies for drug control, distribution, and administration. Because an institution is primarily concerned with preventing health problems resulting from drug use, institutional policies are often more restrictive than government controls. For example, a common institutional policy is the automatic discontinuation of antibiotic therapy after a predetermined number of days. Although a prescriber may reorder an antibiotic, this policy helps to control unnecessarily prolonged drug therapy, which may lead to drug sensitivity or toxic reactions.

Medication Regulation and Nursing Practice.

In Canada, you must be familiar with both the federal and provincial or territorial regulations affecting drug administration in your practice areas. If you move from one province or territory to another, you may

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editiondiscover significant differences in the laws governing drug administration. For example, laws vary concerning the prescription and administration of drugs. In the past, only physicians could prescribe medications. Today, most provinces have amended their nursing practice acts to include the prescription of medications by nurses in advanced practice. In most cases, this privilege is limited to nurse practitioners, clinical nurse specialists, and nurse midwives.

You are responsible for following legal provisions when administering controlled substances (drugs that affect the mind or behaviour), which can be dispensed only with a prescription. Violations of the Narcotic Control Act are punishable by fines, imprisonment, and loss of your nursing licence or your nursing registration. Hospitals and other health care institutions have policies for the proper storage and distribution of controlled substances, including narcotics (Box 34-1).

Pharmacokinetics as the Basis of Medication Actions

For medications to be therapeutic, they must be taken into a client's body, where they are absorbed and distributed to cells, tissues, or a specific organ, and they must alter physiological functions. Pharmacokinetics is the study of how medications enter the body, reach their site of action, metabolize, and exit the body. Use your knowledge of pharmacokinetics when timing medication administration, selecting the route of administration, considering the client's risk for alterations in medication action, and evaluating the client's response.

Absorption.

Absorption refers to the passage of medication molecules into the blood from the medication's site of administration. Medication absorption is affected by the route of administration, the ability of the medication to dissolve, blood flow to the site of administration, the client's body surface area, and lipid solubility (maximum concentration of a chemical that will dissolve in fatty substances) of medication.

Route of Administration.

Each route of medication administration has a different rate of absorption. When medications are applied to the skin, absorption is slow due to the physical makeup of the skin. Medications placed on the mucous membranes and respiratory airways are quickly absorbed because these tissues are highly vascular. Because orally administered medications must pass through the gastrointestinal (GI) tract to be absorbed, the overall rate of absorption is usually slow. Intravenous (IV) injection produces the most rapid absorption because this route provides immediate access to systemic circulation.

BOX 34-1 Guidelines for Safe Narcotic Administration and Control

• Store all narcotics in a locked, secure cabinet or container. (Cabinets with computer-controlled locking devices are preferred.)

• Count narcotics frequently. Count and record inventories on a continuous basis, especially when narcotic drawers are opened and when nursing shifts change.

• Report discrepancies in narcotic counts immediately.

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• Use a special inventory record each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used, narcotics remaining, and information about narcotics that are wasted.

• After dispensing a narcotic, use the record to document the client's name, the date and time of medication administration, the name of the medication, the dose, and your signature.

• If you dispense only part of a premeasured dose of a controlled substance, a second nurse must witness disposal of the unused portion. If paper records are kept, both you and the nurse who witnesses the wastage are required to sign the form. Computerized systems record the nurses' names electronically. Do not place wasted portions in the sharps containers. Instead, flush wasted portions of tablets down a toilet and wash wasted liquids down a sink.

Ability of the Medication to Dissolve.

The ability of an oral medication to dissolve depends on its form or preparation. Solutions and suspensions in a liquid state are absorbed more readily than tablets or capsules. Acidic medications pass through the gastric mucosa rapidly. Medications that have a base pH are not absorbed before reaching the small intestine.

Blood Flow to the Site of Administration.

When the site of administration contains a rich blood supply, the body absorbs medications more rapidly. As blood comes in contact with the site of administration, the medication is absorbed. Therefore, areas that have more blood supply will experience enhanced absorption, facilitating the passage of the medication into the bloodstream.

Body Surface Area.

When a medication is in contact with a large surface area, the medication will be absorbed at a faster rate. This characteristic explains why most medications are absorbed in the small intestine, not in the stomach.

Lipid Solubility of a Medication.

Because the cell membrane has a lipid layer, highly lipid-soluable medications easily cross the cell membrane and are absorbed quickly. The absorption of medication is also affected by the presence of food in the stomach. Some oral medications are absorbed more easily when administered between meals or on an empty stomach because food can change the structure of a medication and impair its absorption. When you administer medications, you should be aware of potential medication—medication interactions listed in the CPS, in drug manuals, and on drug packaging. If medications that interact are ordered at the same time, notify the prescriber immediately to revise medication administration times.

Safe medication administration requires knowledge of factors that may alter or impair the absorption of the prescribed medications. This information is based on an understanding of the medication's pharmacokinetics, the client's history, the physical examination of the client, and knowledge gained

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionthrough daily interactions with clients. Use this knowledge to ensure that you administer all prescribed medications at the correct time. Consult and collaborate with the client's prescribers to ensure the client achieves the therapeutic effect of all medications. Before administering any medication, check pharmacology books or drug references, package inserts, or consult with pharmacists to identify medication—medication interactions or medication—nutrient interactions. Furthermore, because the safe delivery of many medications (e.g., blood pressure—lowering agents, blood glucose—lowering medications, and antiarrhythmics) are dependent on nursing assessments, ensure that physical assessment data are collected and interpreted before administering medications.

Distribution.

After a medication is absorbed by the body, it is distributed to tissues and organs and to its specific site of action. The rate and extent of distribution depend on the physical and chemical properties of the medications and the physiology of the person taking the medication.

Circulation.

After a medication enters the bloodstream, it is carried throughout the body's tissues and organs. The speed at which it reaches the site depends on the vascular content of the tissues and organs. Conditions that limit blood flow or blood perfusion inhibit the distribution of a medications. For example, clients who have experienced congestive heart failure have impaired circulation, which also impairs medication delivery to the intended site of action. Therefore, the efficacy of medications in congestive heart failure clients can be delayed or altered.

Membrane Permeability.

For a medication to be distributed to an organ, it must pass through all the organ's tissues and biological membranes. Some membranes serve as barriers to the passage of medications. For example, the blood—brain barrier allows only fat-soluble medications to pass into the brain and cerebral spinal fluid. Therefore, central nervous system infections require treatment with antibiotics that selectively cross the blood—brain barrier. This change in the permeability of the blood—brain barrier can lead to confusion and other adverse effects in some older clients. The placental membrane also has a nonselective barrier to medications. Fat-soluble and non—fat-soluble agents can cross the placenta and result in fetal deformities, respiratory depression, and, when combined with narcotic use, withdrawal symptoms.

Protein Binding.

Most medications bind to proteins to some extent. The degree to which medications bind to serum proteins, such as albumin, affects the medication's distribution. Medications bound to albumin cannot exert pharmacological activity. The unbound, or free, medication is the active form of the medication. Older adults have a decrease in albumin in their bloodstream, which is probably the result of a change in their liver function. The same is true for clients who have liver disease or malnutrition, who, along with older adults, have the potential for more medication being unbound, and thus may be at risk for an increase in medication activity or toxicity, or both.

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Metabolism.

After a medication reaches its site of action, it metabolizes into a less active or inactive form that is more easily excreted. Biotransformation occurs when enzymes detoxify, degrade (break down), and remove the biologically active chemicals. Most biotransformation occurs within the liver, although the lungs, kidneys, blood, and intestines also metabolize medications. The liver is especially important because its specialized structure oxidizes and transforms many toxic substances. The liver degrades many harmful chemicals before they are distributed to the tissues. If a decrease in liver function occurs, a medication is usually eliminated more slowly and results in an accumulation of the medication. If the organs that metabolize medications are altered, clients are at risk for medication toxicity. For example, a small sedative dose of a barbiturate may cause a client with liver disease to lapse into a hepatic coma.

Excretion.

After medications are metabolized, they exit the body through the kidneys, liver, bowel, lungs, or exocrine glands. The chemical makeup of a medication determines the organ of excretion. Gaseous and volatile compounds, such as nitrous oxide and alcohol, exit through the lungs. Deep breathing and coughing (see Chapter 49) help the postoperative client to eliminate anaesthetic gases more rapidly. The exocrine glands excrete lipid-soluble medications. When medications exit through the sweat glands, the skin often becomes irritated. You can assist the client in good hygiene practices (see Chapter 38) to promote cleanliness and skin integrity. If a medication is excreted through the mammary glands, a nursing infant is at risk of ingesting the chemicals. You will need to check on the safety of any medication used by breastfeeding women.

The GI tract is another route for medication excretion. Many medications enter the hepatic circulation where they are broken down by the liver and excreted into the bile. After chemicals enter the intestines through the biliary tract, they may be reabsorbed by the intestines. Factors that increase peristalsis (e.g., laxatives and enemas) accelerate medication excretion through the feces, whereas factors that slow peristalsis (e.g., inactivity and improper diet) may prolong a medication's effects.

The kidneys are the main organs for medication excretion. Some medications escape extensive metabolism and exit unchanged in the urine. Other medications must undergo biotransformation in the liver before being excreted by the kidneys. If renal function declines, a client is at risk for medication toxicity. If the kidneys cannot adequately excrete a medication, the dose may need to be reduced. Maintenance of an adequate fluid intake (50 mL/kg/day) promotes proper elimination of medications for the average adult.

Types of Medication Action

Medications vary considerably in the way they act and in their types of action. Factors other than characteristics of the medication also influence medication actions. A client does not always respond in the same way to each successive dose of a medication. Sometimes, the same medication causes very different responses in different clients. Therefore, you need to understand all the effects that medications can have on clients.

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Therapeutic Effects.

The therapeutic effect is the expected or predictable physiological response that a medication causes. Each medication has a desired therapeutic effect, which is the reason it is prescribed. For example, nitroglycerine reduces the body's cardiac workload and increases myocardial oxygen supply. A single medication may have more than one therapeutic effect. For example, aspirin reduces platelet aggregation (clumping) and is an analgesic, an antipyretic, and an anti-inflammatory drug. Knowing the desired therapeutic effect for each medication allows you to provide client education to accurately evaluate the medication's desired effect.

Side Effects.

Side effects are the unintended, secondary effects that a medication predictably will cause. Side effects may be harmless or injurious. If the side effects are serious enough to negate a medication's intended beneficial effects, the prescriber may decide to discontinue the medication. Clients often stop taking medications because of side effects.

Adverse Effects.

Adverse effects are severe, negative responses to medication. For example, a client may become comatose after injesting a drug. When adverse responses to medications occur, the prescriber immediately discontinues the medication. Some adverse effects are unexpected effects that were not discovered during drug testing. When this situation occurs, health care professionals should report the adverse effect to the Health Protection Branch of the federal government (http://www.hc-sc.gc.ca/english/protection/drugs.html). This reporting system is voluntary.

Toxic Effects.

Toxic effects develop after prolonged intake of a medication or after a medication accumulates in the blood because of impaired metabolism or impaired excretion. Excess amounts of a medication within the body may have lethal effects, depending on the medication's action. For example, toxic levels of morphine, which is an opioid, may cause severe respiratory depression and death. Antidotes are available to treat specific types of medication toxicity. For example, Narcan is used to reverse the effects of opioid toxicity.

Idiosyncratic Reactions.

Medications sometimes cause unpredictable effects, such as an idiosyncratic reaction, which occurs when a client overreacts or underreacts to a medication or has a reaction different from the normal reaction. For example, a child receiving an antihistamine (Benadryl) may become extremely agitated or excited instead of becoming drowsy. It is not always possible to predict whether a client might have an idiosyncratic response to a medication.

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Allergic Reactions.

Allergic reactions are unpredictable responses to a medication. Some clients become immunologically sensitized to the initial dose of a medication. After repeated administration of the medication, the client develops an allergic response to the medication, its chemical preservatives, or a metabolite. The medication or chemical acts as an antigen, triggering the release of the body's antibodies. A client's medication allergy symptoms may vary, depending on the individual and the medication (Table 34-2). Among the different classes of medications, antibiotics cause a high incidence of allergic reactions.

Anaphylactic reactions are severe reactions that are life-threatening and are characterized by sudden constriction of bronchial muscles, edema of the pharynx and larynx, severe wheezing, shortness of breath, and circulatory collapse. Immediate use of antihistamines, epinephrine, or bronchodilators is required to treat anaphylactic reactions. Emergency resuscitation measures are sometimes required. A client with a known history of an allergy to a medication needs to avoid exposure to that medication and must wear a bracelet or medal engraved with emergency medical information, including medication allergies (e.g., a MedicAlert bracelet Figure 34-2). These bracelets and medals alert health care workers to the client's medical information, including allergies, if the client is unable to communicate this information when receiving medical care. Additionally, some clients with allergies leading to anaphylactic reactions carry their own epinepherine pens.

Medication Interactions

When one medication modifies the action of another medication, a medication interaction occurs. Medication interactions are common in clients who take several medications. Some medications increase or diminish the action of other medications or may alter the way another medication is absorbed, metabolized, or eliminated from the body. When two medications have a synergistic effect, the combined effect of the two medications is greater than the effect of the medications when given separately. For example, alcohol acts as a depressant on the central nervous system and has a synergistic effect on antihistamines, antidepressants, barbiturates, and narcotic analgesics.

Sometimes a medication interaction is desired. Prescribers combine medications to create an interaction that will have a beneficial effect on the client's condition. For example, a client with high blood pressure may be prescribed several medications, such as diuretics and vasodilators, which act together to control blood pressure when one medication alone is not effective.

Medication Dose Responses

After administration, a medication undergoes absorption, distribution, metabolism, and excretion. Except when administered intravenously, medications take time to enter the bloodstream. The quantity and distribution of a medication in different body compartments change constantly. When a medication is prescribed, the goal

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Figure 34-2 A MedicAlert bracelet is engraved with a person's emergency medical information, including drug allergies.

is to achieve a constant blood level of the medication within a safe therapeutic range. Repeated doses are required to achieve a constant therapeutic concentration of a medication because a portion of a drug is always being excreted. The highest serum concentration (peak concentration) of a medication usually occurs just before the body absorbs the last of the medication (McKenry et al., 2006). After peaking, the serum medication concentration falls progressively. After intravenous (IV) infusions, the peak concentration occurs quickly, but the serum level also begins to fall immediately (Figure 34-3). The point at which the lowest amount of drug is detected in the serum is called the trough concentration. Some medications doses (e.g., vancomycin) are based on peak and trough serum levels. The trough level is generally drawn 30 minutes before the drug is administered, and the peak level is drawn whenever the drug is expected to reach its peak concentration. The time a drug takes to reach its peak concentration varies depending on the medication's pharmacokinetics.

TABLE 34-2 Mild Allergic Reactions

SymptomDescriptionUrticaria Raised, irregularly shaped skin eruptions with varying sizes and shapes; eruptions have reddened margins and

pale centre.Rash Small, raised vesicles that are usually reddened; often distributed over entire body.Pruritus Itching of skin; accompanies most rashes.Rhinitis Inflammation of mucous membranes lining nose; causes swelling and clear, watery discharge.

All medications have a serum half-life, which is the time it takes for the excretion processes to lower the serum medication concentration by half. To maintain a therapeutic plateau, the client needs to receive regular fixed doses. For example, current evidence indicates that pain medications are most effective when they are given “around the clock” to maintain an almost constant level of pain medication rather than being given when the client intermittently complains of pain. After an initial medication dose, the client receives each successive dose when the previous dose reaches its half-life.

Together with the client, you need to follow regular dosage schedules and adhere to prescribed doses and dosage intervals (Table 34-3).



Figure 34-3 Curve showing therapeutic blood levels of medication.

Source: From Clark, J. F., Queener, S. F., & Karb, V. B. (1998). Pharmacological basis of nursing practice (6th ed.). St. Louis, MO: Mosby.

Some agencies set schedules for medication administration. However, nurses are able to alter this schedule on the basis of knowledge about a medication. For example, at some agencies, medications prescribed to be taken once a day are given at 9:00 A.M. However, if a medication works best when given before bedtime, administer the medication before the client goes to sleep.

When teaching clients about dosage schedules, use language that is familiar to the client. For example, when teaching a client about medication dosing twice a day, instruct the client to take a medication in the morning and again in the evening. Use knowledge about the time intervals of medications to anticipate a medication's


Canadian Fundamentals of Nursing - Revised Reprint, 4th Editioneffect and to educate the client about when to expect a response. Table 34-4 lists common terms associated with medication actions.

TABLE 34-3 Common Dosage Administration Schedules

Dosage Schedule Abbreviation or Notation*Before meals AC, acAs desired ad libTwice a day [Do not abbreviate]Hour h, hrAt bedtime [Do not abbreviate; write out “nightly or at bedtime”]After meals PC, pcWhenever there is a needprnEvery morning, every A.M. qamEvery day, daily [Do not abbreviate]Every hour qhEvery 2 hours q2hEvery 4 hours q4hEvery 6 hours q6hEvery 8 hours q8hFour times a day [Do not abbreviate]Every other day [Do not abbreviate]Give immediately STATThree times a day [Do not abbreviate]

* For some terms, it is safer to write out the term than to abbreviate it (see Table 34-7). Follow your agency's policy regarding the use of abbreviations.

TABLE 34-4 Terms Associated With Medication Actions

Term MeaningOnset The time it takes for a medication to produce a response after it has been administered.Peak The time it takes for a medication to reach its highest effective concentration.Trough Minimum blood serum concentration of medication, typically reached just before the next scheduled dose.DurationThe time during which a medication is present in sufficient concentration to produce a response.Plateau Blood serum concentration of a medication has been reached and is maintained after repeated fixed doses.



Figure 34-8 West nomogram used to estimate the body surface area of children. A straight line is drawn between a child's height and weight. The point where the line crosses the surface area column is the child's estimated body surface area.

Source: From Behrman, R. E., Kliegman, R., & Jenson, H. B. (2004). Nelson textbook of pediatrics (17th ed.). Philadelphia: Saunders.

34 Medication Administration Page 1 of 36

Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionare accountable for knowing which medications are prescribed, their therapeutic and nontherapeutic effects, and any nursing implications associated with the medications. You are responsible for performing a physical assessment of the client (e.g., monitoring and interpreting blood pressure before administering an antihypertensive medication) and, on the basis of data from the physical assessment, for determining whether a medication is safe to administer. You should also know why the client needs the medication and be able to determine whether the client needs supervision when taking the medication or education about the medication and its effects. Always monitor the effect of the drug after it is administered and report any reactions to the prescriber.

Prescriber's Role

The physician, nurse practitioner, or pharmacist prescribes the client's medication by writing a medication order (prescription) on a form in the client's medical record, in an order book, or on a legal prescription pad; by transmitting the information on a paper form through a facsimile (fax) machine; or by sending the information through a computer terminal. For each medication ordered, prescribers must document the client's diagnosis, condition, or indication for use.

A prescriber may also order a medication by talking directly to the nurse or by telephone. A medication or medical treatment ordered in this way is called a verbal order. When you receive a verbal order, read it back and receive confirmation from the prescriber to ensure accuracy (Box 34-4). Immediately enter the order into the client's medical record and record the time and the name of the prescriber who gave the order (The Joint Commission, 2007). Lastly, sign the record. Most institutions require a prescriber's signature within 24 hours after the order is made. Institutional policies vary regarding the personnel who are authorized to receive verbal or telephone orders. Nursing students cannot receive these types of medication orders. Nursing students give newly ordered medications only after the order has been written and verified by a registered nurse.

Common abbreviations are used when writing orders. Abbreviations indicate dosage frequencies or times, routes of administration, and special information for administering the medication (see Table 34-3). Caution must be exercised when you use abbreviations because some shortened forms can lead to confusion and the potential for medication errors (Table 34-7). It is important to know your agency's policies on abbreviations. Do not use error-prone abbreviations when documenting medication orders or other information about medications (Institute for Safe Medication Practices, 2006a; National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP], 2006; The Joint Commission, 2007).

Types of Orders

Five types of medication orders are common in acute care settings: routine, “prn,” single (one-time), “STAT,” and “now” orders. Medication orders are based on the frequency and the urgency of medication administration. Some conditions change the status of a client's medication orders. For example, in some agencies, the client's preoperative medications are automatically discontinued after surgery, and the health care professional needs to write new medication orders (see Chapter 49). The prescriber should review the medications and write new orders when a client is transferred to another health care agency, relocated to a different service within a hospital, or discharged.

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Routine Medication Orders.

A routine order is carried out until the prescriber cancels it by writing a new order or until a prescribed number of days have elapsed. A routine order may indicate a final date or the total number of treatments or doses. Many institutions have policies for automatically discontinuing routine orders. The following are examples of routine orders: “tetracycline 500 mg PO q6h” and “Decadron 10 mg daily × 5 days.”

As-Needed (“prn”) Orders.

According to a “prn” order, a medication is to be given only when a client requires it. Use your skills in objective and subjective assessment and discretion when determining whether the client needs the medication. Often, the prescriber sets minimum intervals for the time of administration, which requires the medication not be given more often than a prescribed period of time. An example is “morphine sulphate 5 mg subcutaneously q3—4 h prn for incisional pain.” This order indicates that the client needs to wait at least 3 hours between doses. When administering medications, document the assessment made and the time of medication administration. Make frequent evaluation of the effectiveness of the medication and record your findings in the appropriate record.

Single (One-Time) Orders.

A prescriber will often order a medication to be given only once at a specified time. This order is common for preoperative medications or medications given before diagnostic examinations: for example, “Versed 25 mg IM on call to OR” and “Valium 10 mg PO at 0900.”

STAT Orders.

A STAT order signifies that a single dose of a medication is to be given immediately and only once. STAT orders are often written for emergencies when the client's condition changes suddenly: for example, “Give Apresoline 10 mg IV STAT.”

BOX 34-4 Recommendations Designed to Reduce Medication Errors Associated With Verbal Medication Orders and Prescriptions

Council Recommendations to Reduce Medication Errors Associated With Verbal Medication Orders and Prescriptions

Adopted February 20, 2001

Revised February 24, 2006

Preamble

Confusion over the similarity of drug names accounts for approximately 25% of all reports to the USP Medication Errors Reporting (MER) Program. To reduce confusion pertaining to verbal

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionorders and to further support the Council's mission to minimize medication errors, the following recommendations have been developed.

In these recommendations, verbal orders are prescriptions or medication orders that are communicated as oral, spoken communications between senders and receivers face to face, by telephone, or by other auditory device.

Recommendations

1. Verbal communication of prescription or medication orders should be limited to urgent situations where immediate written or electronic communication is not feasible.

2. Health care organizations* should establish policies and procedures that:

• Describe limitations or prohibitions on use of verbal orders

• Provide a mechanism to ensure validity/authenticity of the prescriber

• List the elements required for inclusion in a complete verbal order

• Describe situations in which verbal orders may be used

• List and define the individuals who may send and receive verbal orders

• Provide guidelines for clear and effective communication of verbal orders.

3. Leaders of health care organizations should promote a culture in which it is acceptable, and strongly encouraged, for staff to question prescribers when there are any questions or disagreements about verbal orders. Questions about verbal orders should be resolved before the preparation, or dispensing, or administration of the medication.

4. Verbal orders for antineoplastic agents should not be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they have a narrow margin of safety.

5. Elements that should be included in a verbal order include:

• Name of client

• Age and weight of client, when appropriate

• Drug name

• Dosage form (e.g., tablets, capsules, inhalants)

• Exact strength or concentration

• Dose, frequency, and route

• Quantity and duration

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• Purpose or indication (unless disclosure is considered inappropriate by the prescriber)

• Specific instructions for use

• Name of the prescriber and, when appropriate, the telephone number

• Name of individual transmitting the order, if different from the prescriber

6. The content of verbal orders should be clearly communicated:

• The name of the drug should be confirmed by any of the following:

• Spelling

• Providing both the brand and generic names of the medication

• Providing the indication for use

• To avoid confusion with spoken numbers, a dose such as 50 mg should be dictated as “fifty milligrams … five zero milligrams” to distinguish from “fifteen milligrams … one five milligrams.”

• To avoid confusion with drug name modifiers, such as prefixes and suffixes, additional spelling-assistance methods should be used (i.e., S as in Sam).

• Instructions for use should be provided without abbreviations. For example, do not record “1 tab TID” communicate the instruction as “Give one tablet three times daily.”

• Whenever possible, the receiver of the order should write down the complete order to enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result.

7. All verbal orders should be committed immediately to writing and the written record should be signed by the individual receiving the order.

8. Verbal orders should be documented in the client's medical record, reviewed, and countersigned by the prescriber as soon as possible.

* Health care organizations include community pharmacies, physicians' offices, hospitals, nursing homes, home care agencies, and so on.

Copyright 1998—2007, National Coordinating Council for Medication Error Reporting and Prevention. All rights reserved.



Now Orders.

A “now” order is more specific than a one-time order; it is used only once, when a client needs medication quickly but not immediately, as in a STAT order. When you receive a “now” order, you have up to 90 minutes to administer the medication. An example of a “now” order is “Give Vancomycin 1 g IV piggyback now.”

Prescriptions.

The prescriber writes prescriptions for clients who are to be administered medications outside of the hospital setting. The prescription includes more detailed information than a regular order because the client must understand how to take the medication and when to refill the prescription if a refill is necessary. The parts of a prescription are illustrated in Figure 34-9. You need to assess the client's accessibility to pharmacies and other health care resources to determine whether the client needs additional support in the community.

Pharmacist's Role

The pharmacist prepares and distributes prescribed medications. Pharmacists work with nurses, physicians, and other health care professionals to evaluate the efficacy of clients' medication. The pharmacist is responsible for filling prescriptions accurately and for ensuring the prescriptions are valid. The pharmacist in a health care agency rarely needs to mix compounds or solutions, except in the case of intravenous solutions. Most medication companies deliver medications in a form that is ready for use. The pharmacist's main task is dispensing the correct medication in the proper dosage and amount and labelling the medication accurately. The pharmacist also provides information about medication side effects, toxicity, interactions, and incompatibilities.

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TABLE 34-7 Abbreviations, Symbols, and Dose Designations With Potential I for Errors in Medication Administration

Intended Abbreviation Meaning Misinterpretation CorrectionU or u Unit Can be mistaken for the number 0 or 4, causing

a 10-fold overdose or greater (e.g., “4U” can be misread as “40,” or “4u” can be misread as “44”); can be mistaken for “cc,” causing the dose to be administered in volume instead of in units (e.g., “4u” can be misread as “4cc”)

Write out “unit”

IU International unit Can be mistaken for “IV” (intravenous) or “10” (ten)

Write out “international unit”

Q.D., q.d., QD, or qd Every day Can be mistaken for “q.i.d,” especially if the period after the letter “q” or the tail of the letter “q” is misunderstood as the letter “I”

Write out “daily”

Q.O.D., q.o.d, QOD, or qod

Every other day Can be mistaken for “q.d.” (daily) or “q.i.d.” (four times daily) if the letter “o” is poorly written

Write out “every other day”

MS, MSO4 Morphine sulfate Can be mistaken for magnesium sulfate Write out the complete drug name

MgSO4 Magnesium sulfate Can be mistaken for morphine sulfate Write out the complete drug name

μg Microgram Can be mistaken for “mg” (milligram) Write the abbreviation “mcg”

hs At bedtime, hours of sleep (hora somna)

Can be mistaken for “half-strength” Write out “bedtime” or “half-strength”

T.I.W. or tiw 3 times a week Can be mistaken for 3 times a day or twice in a week

Write out “three times weekly”

S.C., S.Q., SC, and SQ Subcutaneous SC can be mistaken for S.L. (sublingual); SQ can be mistaken for the words “5 every”: the letter “q” in “sub q” can be mistaken for the word “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” can be misunderstood as being required every 2 hours before surgery)

Write the abbreviation “subcut” or the term “subcutaneously”

D/C Discharge or discontinue

When “discharge” is intended, can be mistaken for premature “discontinuation of medications,” especially when followed by a list of discharge medications

Write out “discharge” and “discontinue”

cc Cubic centimeters Can be mistaken for the letter “u” (units) Use the abbreviation “mL”

Adapted from The Joint Commission for Accreditation of Health Care. (2004). 2004 National patient safety goals: FAQs. Retrieved January 8, 2009, from http://www.premierinc.com/safety/safety-share/10-03-downloads/01-2004-JCAHO-no7-NPSG.doc

Distribution Systems

Systems for storing and distributing medications vary. Pharmacists provide the medications, but nurses distribute the medications to clients. Institutions that provide nursing care reserve a special area for stocking and dispensing medications. Examples of medication storage areas are special medication rooms, portable locked carts, medication cabinets with computer-controlled locking devices, and individual storage units next to clients' rooms. Ensure that all medications are in locked containers in a room (e.g., a medication room) or are under constant surveillance.

34.4.5



Stock Supply System.

In a stock system, medications are available in quantity, in large, multidose containers. The stock system is time-consuming and costly because a nurse must dispense each medication separately for each client. This type of medication delivery has been associated with a high rate of medication errors and is not commonly used today.

Unit-Dose System.

The unit-dose system uses portable carts containing a drawer with a 24-hour supply of medications for each client. Each drawer is labelled with the name of a client. The unit dose is the ordered dose of medication the client receives at one time. Each tablet or capsule is wrapped in a foil or paper container. At a designated time each day, the pharmacist or a pharmacy technician refills the drawers in the cart with a fresh supply. The cart also contains limited amounts of “prn” and stock medications. Controlled substances

Figure 34-9 Sample medication prescription.

are not kept in the individual client drawers; they are kept in a larger locked drawer. The unit-dose system is designed to reduce the number of medication errors and to save the steps required when dispensing medications.

Automated Dispensing Systems.

Automated medication dispensing systems (AMDS) are used successfully throughout Canada (Figure 34-10). These systems use computerized controls to dispense narcotics and unit-dose medication. Each nurse accesses the system by entering a security code. All procedures connected to an AMDS are controlled electronically via a client's profile. The client's name and drug profile must be accessed before the AMDS

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionwill dispense a medication. The nurse enters the client's identification number into the computer and selects the desired medication, the correct dose, and the route from a display on the computer screen. The system opens the

Figure 34-10 Nurse using automated medication dispensing system.

drawer containing the medication and records the transaction. Nurses may also scan bar codes to identify the client, medication (name, dose, route), and the nurse administering the medication. This information is then automatically recorded in a computerized database.

Nurse's Role

Administering medications to clients requires knowledge and skills that are unique to nurses. You must first determine that the medication ordered is the correct medication. Do not assume that all medications in the client's drawer or pill box are to be given to the client. Collect and interpret physical assessment data to determine whether a client should receive a medication at a given time, administer medications correctly, and monitor the effects of prescribed medications. Assess the client's ability to self-administer medications. An integral part of your role is educating the client and the client's family about proper medication administration and monitoring. Do not delegate any part of the medication administration process to unregulated care providers, and use the nursing process to integrate medication therapy into nursing care.

Medication Errors.

A medication error is any event that could cause or lead to a client either receiving inappropriate medication therapy or failing to receive appropriate medication therapy. Most errors made by nurses are

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionmedication errors. A medication error can cause or lead to inappropriate medication use or client harm. A medication error can occur when you neglect routine procedures, such as checking dose calculations; administer unfamiliar medications; neglect to administer an ordered medication; fail to comply with the seven rights of medication administration; and fail to perform necessary assessments before medication administration (e.g., monitoring the client's blood glucose levels or blood pressure). Additional system issues that can lead to medication errors include distraction, illegible orders, transcription errors, and inappropriate use of abbreviations. Hospital medication delivery systems should be designed so that a system of checks and balances help reduce medication errors.

To demonstrate accountability and acting responsibly in professional practice, you need to acknowledge your errors when they occur. Because nurses play an essential role in the preparation and administration of medications, you need to be vigilant in preventing medication errors (Box 34-5) and advocate for work environments that are conducive to safe medication administration (Box 34-6).

Medication errors can also result from the design of health care products or from procedures and systems, such as product labelling and distribution. When an error occurs, the client's safety and well-being is top priority. Assess the client's condition and notify the physician or prescriber of the medication error as soon as possible. You may need to take measures to counteract the error. After the client's condition has stabilized, report the incident to the appropriate person in the institution (e.g., a manager or supervisor).

When a medication error occurs, you are responsible for preparing a written occurrence or incident report, which usually needs to be filed within 24 hours of the error. The report includes the client identification information; the location and time of the incident; an accurate, factual description of the error that occurred and measures taken to address the error; and your signature. The occurrence report is not a permanent part of the client's medical record and is not referred to in the record (see Chapters 9 and 18), which legally protects the health care professional and the institution. Institutions use occurrence reports to track incident patterns and to address quality improvement and risk-management issues. Many institutions have procedures in place for disclosing incidents to clients or their family members.

Report all medication errors, including errors that do not cause obvious or immediate harm and near misses. It is important for you to feel comfortable in reporting an error and not fear repercussions from managerial staff. Even when a client suffers no harm from a medication error, the institution can still learn why the mistake occurred and what steps can be taken to avoid similar errors in the future. Creating a culture of safety through strategies such as “Good Catch” or “Near Miss” reporting is becoming a popular method for addressing medication safety. Table 34-8 outlines error-prone conditions that lead to student nurse—related errors and specific strategies for avoiding these errors.

BOX 34-5 Steps to Take to Prevent Medication Errors

• Follow the seven rights of medication administration.

• Be sure to read labels at least three times (comparing medication administration record with label) before, during, and after administering the medication.

• Use at least two client identifiers whenever administering a medication.

• Do not allow any other activity to interrupt administration of medication to a client.

• Double-check all calculations, and verify with another nurse.

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• Do not interpret illegible handwriting; clarify with prescriber.

• Question unusually large or small doses.

• Document all medications as soon as they are given.

• When you have made an error, reflect on what went wrong and ask how you could have prevented the error.

• Evaluate the context or situation in which a medication error occurred. This helps to determine whether you have the necessary resources for safe medication administration.

• When repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors and take corrective actions.

• Attend in-service programs that focus on the medications commonly administered.

Reprinted with permission of the National Coordinating Council for Medication Error Reporting and Prevention. © 2006. All rights reserved.

BOX 34-6 Informatics and Medication Safety

Many medication errors occur when the nurse incorrectly administers medications at the client's bedside. The following innovations and advances in technology help to reduce the number of medication errors in nursing practice:

• Networked computers allow all the client's health care professionals to see a current list of ordered and discontinued medications.

• Internet and intranet access allow nurses and other health care professionals to access current information about medications (e.g., indications, desired effects, adverse effects) and specific agency policies that address medication administration (e.g., how fast to administer an intravenous [IV] push medication, how to administer medications through a nasogastric tube).

• In some agencies, prescribers enter medication orders directly into a networked computer system or a personal handheld computer.

• Automated medication dispensing systems and electronic medication administration records help with medication reconciliation, administration, and documentation (Manno, 2006; Paoletti et al., 2007).

• Bar-coding technology requires nurses to scan the medication, the client's identification bracelet, and the nurse's identification badge before administering the medication. This process helps to ensure compliance with the seven rights of medication administration (Mills et al., 2006; Paoletti et al, 2007; Skibinski et al., 2007).

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Application to Nursing Practice

• Actively participate in the selection and evaluation of advanced technologies and the creation of nursing policies and protocols used for medication administration.

• Always follow agency policies when administering medications.

• Implement agency policies for when the technology cannot be used (e.g., during computer down time or power outages).

• Follow the manufacturer's guidelines for care of electronic equipment and report problems with technology immediately.

Medication errors often occur when a client is transferred to a different unit within a hospital or to another health care agency. Therefore, reconciling the list of client's medications during the transfer process is an important part of ensuring safe client care (The Joint Commission, 2007). Nurses play an essential role in medication reconcilliation (Box 34-7).

When admitting a client to any health care setting, compare the medications the client took in the previous setting (e.g., at home or in another nursing unit) with the client's current medication orders (Ptasinski, 2007). When a client is discharged, review the client's current medications with the health care professionals in the new setting. This action, medication reconciliation, may be time-consuming, but it is an essential step in ensuring medication safety. When reconciling medications, consult with the client, the client's caregivers and family members, the physician or advanced practice nurse, and the pharmacist.

TABLE 34-8 Error-Prone Conditions Leading to Student Nurse-Related Errors

BOX 34-7 Process for Medication Reconciliation

1. Verify: Obtain a current list of the client's medications.

2. Clarify: Ensure the accuracy of the medications, dosages, and frequencies; clarify the content of the list with as many people as necessary (e.g., the client, caregivers, health care professionals, pharmacists).

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3. Reconcile: Compare new medication orders against the current list; investigate any discrepancies by contacting the client's health care professional.

4. Transmit: Communicate the updated and verified list to caregivers and the client as appropriate.

Adapted from Ptasinski, C. (2007). Develop a medication reconciliation process. Nurse Manager, 38, 18.

Critical Thinking

Knowledge

To understand why a particular medication has been prescribed for a client and how the medication will alter the client's physiology and have a therapeutic effect, use knowledge you have acquired from many disciplines. For example, from physiology, you learn that potassium is a major intracellular ion. When clients do not have enough potassium in their body (hypokalemia), they experience signs and symptoms such as muscle fatigue or weakness. In some cases, severe hypokalemia is fatal because of the dysrhythmias that may occur as a result. To restore the client's potassium level to normal, medications may be prescribed, which will also relieve the client's signs and symptoms of hypokalemia.

Nurses administer a wide variety of medications, and new medications are constantly being approved for dispensation. As a result, you may not always have knowledge about the medications you are asked to administer. Responsible nurses admit what they do not know and acquire the knowledge needed to safely administer unfamiliar medications by consulting a medication book, electronic computer manuals, the prescriber, or a pharmacist.

Experience

Nursing students often have limited experience with medication administration as it applies to professional practice. Clinical experiences provide nursing students with the opportunity to apply the nursing process to medication administration. As you gain experiences in medication administration, your psychomotor skills (the steps you take to complete the task) become more refined; however, psychomotor skills represent only a small part of medication administration. The client's attitudes, knowledge, physical and mental status, and responses can make medication administration a complex experience.

Cognitive and Behavioural Attributes

Every step of safe medication administration requires a disciplined attitude and a comprehensive, systematic approach. To be consistent with professional, ethical, and legal nursing standards, you must always accept full responsibility for all your actions related to medication administration. When administering a medication to a client, ensure that your nursing actions do not harm the client in any way. Do not assume that the medication ordered for the client is the correct medication or the correct dose. You can be held accountable for administering an ordered medication that is knowingly inappropriate for the client. Thus, for all medications that you administer, you need to be familiar with the therapeutic effect, usual dosage, laboratory interferences,

34.5

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionand side effects. Before administering medications, you must conduct a comprehensive physical assessment of the client and critically analyze the assessment data. You are also responsible for ensuring that clients who will self-administer medications have been properly informed about all aspects of self-administration.

Institutional policy may limit your ability to administer medications in certain units in acute care settings. You may be limited by certain medication routes or by certain dosages. In most institutions, nursing procedure manuals list the institution's policies that define the classes of medications that nurses may and may not administer. The types and doses of medications that nurses may deliver can also vary from unit to unit within the same facility. For example, Dilantin, a powerful medication that is prescribed to treat seizures, may be administered by mouth or by IV push. In large doses, Dilantin can affect the rhythm of the heart. Therefore, when a nursing unit does not have the ability to monitor the client's heart rate and rhythm, some institutions limit the amount of Dilantin that can be given to a client. To ensure safe medication administration, you must adhere to evidence-informed practice guidelines and agency policy and procedure. Not all prescribers are aware of the limitations of all health care institutions and may prescribe medications that cannot be given in a particular health care setting. You must recognize this possibility and ensure that the prescriber is informed of any limitations.

Standards

Standards are actions that ensure safe nursing practice. In Canada, the activity of medication administration by registered nurses is governed by the Canadian Nurses Association's Code of Ethics and professional practice standards set by provincial and territorial nursing associations. Nurses are legally and ethically responsible to acquire the knowledge needed to administer medications and to uphold the client's rights, dignity, and uniqueness in the process. To ensure safe nursing practice, each time you administer a medication, you must be aware of the seven rights of medication administration. All medication errors can be linked, in some way, to an inconsistency in adhering to the following seven rights of medication administration:

1. The right medication

2. The right dose

3. The right client

4. The right route

5. The right time

6. The right documentation

7. The right reason

Right Medication.

A medication order is required for every medication you administer to a client. When medications are first ordered, compare the medication administration record or computer order with the prescriber's written order. Always verify new medication information when new orders are written or when clients transfer from one nursing unit or health care facility to another (The Joint Commission, 2007). When administering medications, compare the label of the medication container with the medication form. Check the label

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionagainst the medication form three times: (1) before removing the container from the drawer or shelf; (2) when the amount of medication ordered is removed from the container; and (3) before returning the container to storage. Never prepare medications from unmarked containers or from containers with illegible labels (The Joint Commission, 2007). When you are using unit-dose prepackaged medications, check the label against the medication administration record when taking medications out of the medication dispensing system. After you determine that the information on the client's medication administration record is accurate, the record is used to prepare and administer the medications. Verify all medications against the medication administration record at the client's bedside before opening the medication packages and delivering the medications to the client.

Administer only the medications that you prepare. If an error occurs, the nurse who administers the medication is responsible. If a client questions the medication, do not ignore the client's concerns. An alert client will know whether a medication is different from one previously received. In most cases, the client's medication order has been changed; however, the client's questions might reveal an error. If an error does occur, withhold the medication and recheck it against the prescriber's orders.

Clients who self-administer medications should keep the medications in their original labelled containers, separate from other medications, to avoid confusion. Many hospitals request that all medication in the hospital setting be administered by nurses, rather than allowing clients to self-administer; this process ensures that clients do not receive double doses of medication. If a client refuses a medication, you should discard it; do not return it to the original container. Unit-dose packaged medications can be saved if they are unopened. However, because of infection control, some agencies require medication to be discarded if it has been taken into a client's room. If a client refuses narcotics, follow the proper hospital procedure of having another nurse witness the wastage of the medication.

Right Dose.

The unit-dose system is designed to minimize errors. The chance of error increases when a medication must be prepared from a larger volume or strength than needed or when the prescriber, in ordering a medication, uses a system of measurement different from what the pharmacist supplies. When you perform a medication calculation or conversion, ensure that another nurse verifies the calculated dose.

After confirming the calculated dose, prepare the medication by using standard measurement devices. Use graduated cups, syringes, and scaled droppers to measure medications accurately. At home, clients should use measuring spoons and cups, not household spoons and cups, which vary in volume.

Only tablets that are scored by the manufacturer should be broken. When you need to break a scored tablet, ensure the break is even. You may cut a tablet in half by using a knife or a pill-cutting device. Discard tablets that do not break evenly. Some agencies allow nurses to save the unadministered portion of the scored medication tablet for subsequent doses if the remaining tablet is repackaged and labelled. Verify with agency policy before administering a tablet that has been opened, cut, and repackaged. In the home care setting, pill splitting is particularly problematic. The Institute of Safe Medication Practices (2006b) has developed suggestions to help with this process. Determine whether the client has both the motor dexterity and visual acuity needed to split tablets. If possible, prescribers need to avoid ordering medications that require splitting.

Often a nurse prepares a tablet by crushing it so that it can be mixed in food. The crushing device should always be cleaned completely before the tablet is crushed. Remnants of previously crushed medications may increase a medication's concentration or result in the client receiving a portion of an unprescribed

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionmedication. Crushed medications should be mixed with very small amounts of food or liquid. Do not mix crushed medications with the client's favourite foods or liquids because a medication may alter the taste of the food or liquid, and thereby decrease the client's desire for them. Pay particular attention to this concern when administering crushed medications to pediatric clients.

safety alert

Not all medications can be crushed. Some medications, such as time-released or extended-release capsules, are coated with special material to prevent the medication from being absorbed too quickly. Before crushing a medication, refer to a medication manual or another medication reference to ensure that the medication can be safely crushed.

Right Client.

Medication errors often occur because one client receives a medication intended for another client. An important step in administering medications safely is to ensure medications are given to the right client. Remembering every client's name and face is difficult. To identify a client correctly, check the medication administration record against the client's identification bracelet and ask the client to state his or her name to ensure that the client's identification bracelet has the correct information (Figure 34-11).

If an identification bracelet is missing or the text is smudged or illegible, acquire a new bracelet for the client. When asking the client's name, you should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, ask the client to state his or her full name. To avoid making the client feel uneasy, simply explain that the question is routine for giving a medication.

Right Route.

If a prescriber's order does not designate a route of administration, or if the specified route is not the recommended route, always consult with the prescriber.

When administering injections, take precautions to ensure that the medications are given correctly. Prepare injections only from preparations designed for parenteral use. The injection of a liquid designed for oral use can produce local complications, such as a sterile abscess, or fatal systemic effects. Medication companies label parenteral medications “for injectable use only.”

Right Time.

Nurses must know why a medication is ordered for certain times of the day and whether the time schedule can be altered. For example, two medications are ordered: one q8h (every 8 hours) and the other three times a day. Both medications are scheduled three times within a 24-hour period. The prescriber intends the

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Figure 34-11 Before administering any medications, the nurse checks the client's identification bracelet.

Source: From deWit, S. (2005). Fundamental concepts and skills for nursing (2nd ed.). Philadelphia, PA: W.B. Saunders.

q8h medication to be given around the clock to maintain therapeutic blood levels of the medication. In contrast, you need to give the three-times-a-day medication during the waking hours. Each institution has a recommended time schedule for medications ordered at frequent intervals. You may alter these recommended times if necessary or appropriate.



The prescriber often gives specific instructions for the timing of administration of a medication. For example, when a preoperative medication is to be given “on call,” you need to administer the medication when the operating room notifies the nursing unit that the client can be transferred for surgery. A medication ordered pc (after meals) is to be given within half an hour after a meal, when the client has a full stomach. A “STAT” medication is to be given immediately.

Give priority to medications that must act at certain times. For example, insulin should be administered at a precise interval before a meal. Antibiotics should be administered on time around the clock to maintain therapeutic blood levels. All routinely ordered medications should be given within 60 minutes of the times for which they are ordered (i.e., 30 minutes before or after the prescribed time).

Some medications require you to use your clinical judgement to determine the proper time for administration. A “prn” sleeping medication should be administered when the client is prepared for bed or at another time appropriate for maximum benefit. Use your judgement when administering “prn” analgesics. For example, you may need to obtain a STAT order from the prescriber if the client requires a medication before the “prn” interval has elapsed. Always document your calls to the client's prescriber that were made to obtain a change in the medication order.

Before a client is discharged from the hospital setting, evaluate the client's need for home care, especially if the client was admitted to the hospital as the result of a problem with medication self-administration. Clients often leave the hospital with a basic knowledge of their medications but are unable to retreive and implement this knowledge after they return home. Before discharge, evaluate whether medications are adequate or are prescribed at therapeutic levels for the client. At home, a client may need to take several medications throughout the day. Help clients to plan their schedules on the basis of preferred medication intervals, the medications' pharmacokinetics, and the clients' own daily schedule. For clients who have difficulty remembering when to take medications, make a chart that lists the times when each medication is to be taken or prepare a special container to hold each timed dose.

Right Documentation.

Nurses and other health care professionals use accurate documentation to communicate with each other. Correct documentation is essential to ensure safe medication administration. Because medication errors may result from inaccurate documentation, ensure that the documentation is appropriate before giving the medications. Appropriate documentation includes the client's name; the name of the ordered medication written out in full (no medication name abbreviations); the time the medication was administered; and the medication's dose, route, and frequency. Common problems with medication orders are incomplete information, inaccurate dose form or strength, illegible orders or signatures, incorrect placement of decimals leading to the wrong dosage, and nonstandard terminology (Hughes & Oritz, 2005). If any pieces of information are missing, contact the prescriber to verify the order. The prescribing health care professional is responsible for providing accurate, complete, and understandable medication orders.

After you administer a medication, complete the medication administration record according to agency policy to verify that the medication was administered as ordered. You are also responsible for documenting any preassessment data regarding the administration of certain medications (e.g., antihypertensive medications, blood glucose—lowering agents, and medications for pain management). Innaccurate documentation of medications, such as failing to document an administered medication, or documenting an incorrect dose, can lead to errors in subsequent decisions about the client's care. For example, errors in

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editiondocumentation about insulin often result in negative client outcomes. Consider the following situation: A client receives insulin at breakfast, but the nurse who gave the insulin neglected to document it. The nurse goes home, and a new nurse is assigned to care for the client. The new nurse notices that the previous nurse did not document the insulin and assumes that the ordered insulin was not given. Therefore, the new nurse gives the client another dose of insulin. Two hours later, the client experiences a low blood glucose level that causes the client to experience seizures. Timely and accurate documentation would have prevented this situation.

Right Reason.

Nurses are professionally responsible for obtaining the rationale for prescribed medications. If you are unaware of a new medication, you have the professional responsibility to research the medication by using the following sources: the Compendum of Pharmaceuticals and Specialties (CPS), drug manuals, or electronic drug information databases. When retrieving information about a medication, be attentive to nursing implications, including routes of administration, preadministration physical assessments, expected onset of action, contraindications, and follow-up nursing assessments and evaluation for both adverse effects and desired responses. You are professionally obligated to contact the prescriber for verification in any of the following situations: a prescriber orders a drug that you identify as contraindicated on the basis of either the client's medical history or the client's current condition, the ordered dose exceeds the recommended limits, or the ordered route is contraindicated for the client. Being vigilant in critically assessing a client's medication regimes is essential to maintain client safety.

Risk Management: Agency Policy and Procedure.

Most institutions have nursing policy and procedure manuals to guide nursing practice. These manuals are updated annually based on current evidence-informed practice literature. Policy and procedure manuals contain vital information for medication administration, including the types of medications nurses are permitted to administer, the preparation of medications, the administration of medications, and guidelines for evaluating client's response to medications. For example, some agencies require nurses to complete specialized training to qualify them to safely administer intravenous chemotherapeutic agents. Furthermore, the administration of certain medications (e.g., intravenous inotropic medications for regulating a client's blood pressure) are prohibited on general medicine and surgery units and permitted only in critical care areas where the client is continuously monitored for responses to medication therapy.

Maintaining Clients' Rights.

Because of the potential risks related to medication administration, clients have the right to the following:

• To be informed of the medication's name, purpose, action, and potential undesired effects

• To refuse a medication regardless of the consequences

• To have qualified nurses or physicians assess their medication history, including allergies and use of herbal therapies (Box 34-8)

• To be properly advised of the experimental nature of medication therapy and to give written consent for its use

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• To receive labelled medications safely without discomfort in accordance with the seven rights of medication administration

BOX 34-8 Nursing Assessment Questions

• What prescription and nonprescription medications do you take, when do you take them, and how do you take them? Do you have a list of medications from your pharmacy or your health care professional?

• What are your medications for?

• What side effects have you experienced?

• Have you ever stopped taking your medications? If so, why did you stop taking them?

• How do you help yourself to remember to take your medications?

• Do you have any allergies to medications or foods? If so, describe what happens when you take the medication or eat the food.

• Describe your normal eating patterns. What foods do you eat, and at what times do you normally eat?

• How do your religious or cultural beliefs influence your beliefs about your medications?

• How do you pay for your medications? Do you have additional insurance through your employer or pension plan to help cover the costs of your medication? Do you live close to a pharmacy? How do you access prescription medications in your community?

• What questions do you have about your medications?

• To receive appropriate supportive therapy in relation to medication therapy

• To not receive unnecessary medications

• To be informed whether medications are part of a research study

Be aware of these rights and handle all inquiries by clients and their families courteously and professionally. If a client refuses medication therapy, do not become defensive. Recognize that every person of consenting age has the autonomous right to refuse a medication.

Nursing Process and Medication Administration

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Assessment

To determine the need for and potential response to medication therapy, nurses assess many factors. To ensure safe medication administration, perform thorough physical assessments of all clients before administering medications.

History

Before administering medications, you need to obtain or review the client's medical history. A client's medical history provides indications or contraindications for medication therapy. A client who has disease or illness is at risk for adverse medication effects. For example, if a client has a gastric ulcer, compounds containing aspirin will increase the likelihood of bleeding. If a client has a long-term health condition, such as diabetes or arthritis, the client requires medications to treat these conditions. A client's surgical history may also indicate the use of medications. For example, after a thyroidectomy, a client may require hormone replacement.

History of Allergies

If the client has a history of contact allergies or allergies to medication or food, inform the other members of the health care team. Food allergies should be carefully documented because many medications include ingredients also found in food sources. For example, a client who is allergic to shellfish may also be sensitive to any product containing iodine, such as Betadine or dyes used in radiological testing. To ensure client safety, when clients are admitted to a hospital, they are issued an identification band that lists the medications they are allergic to. Ensure that all allergies are noted on the nurse's admission notes, the medication records, and the physician's documentation of the client's history.

Medication Data

Assess information about each medication that the client takes, including length of time the medication has been taken, the current dosage, and whether the client has experienced any adverse effects. Review the medication data, including the action, purpose, normal dosages, routes, side effects, and nursing implications for administration and monitoring. Common questions to ask include the following: Is the smallest possible dose ordered? (a question pertinent for medications ordered for older adults) Can a certain medication interact with other medications the client is taking? Are special instructions required for administering the medication? Often, several resources must be consulted to gather the information you need. Some valuable resources are pharmacology textbooks, nursing journals, the Compendium of Pharmaceuticals and Specialties (CPS), online medication manuals, medication package inserts, nursing journals, and the pharmacist. You are responsible for knowing as much as possible about each medication you administer. Many nursing students prepare or purchase cards containing medication data to use as a quick resource.

Diet History

A diet history reveals the client's normal eating patterns and food preferences. Nurses can then plan the dosage schedule more effectively and advise clients to avoid foods that may interact with their medications. Be aware

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionof clients' cultural preferences for food, and if these foods interact with medications, provide the clients and their families with comprehensive, respectful explanations.

Client's Perceptual or Coordination Problems

For a client with limited perceptual, fine motor, or coordination skills, self-administration of medication may be difficult. For example, a client with arthritis who takes insulin to manage blood glucose levels may have difficulty manipulating a syringe. Always assess the client's ability to prepare doses and take medications correctly. If the client is unable to self-administer medications, determine whether a family member or friend will be available to assist the client, or collaborate with the interdisciplinary team to refer the client to a home care service that can assist in medication administration.

Client's Current Condition

The physical or mental status of a client may affect whether a medication is given or how it is administered. Carefully assess a client before giving any medication. For example, check the client's blood pressure before giving an antihypertensive medication. A client who is nauseated may be unable to swallow a tablet. Assessment findings also serve as a baseline in evaluating the effects of medication therapy.

Client's Attitude Toward Medication Use

The client's attitude about medications may reveal the client's level of medication dependence or drug avoidance. Clients may not express their feelings about taking a particular medication, particularly if they have become dependent on it. Observe the client's behaviour for evidence of medication dependence or avoidance. Also be aware that the client's cultural beliefs about Western medicine could interfere with medication compliance (Box 34-9, and see Chapter 10).

Client's Knowledge and Understanding of Medication Therapy

The client's knowledge and understanding of medication therapy influence the willingness or ability to follow a medication regimen. Compliance is unlikely unless a client understands the medication's purpose, the importance of regular dosage schedules and proper administration methods, and the medication's possible side effects. When assessing a client's knowledge of a medication, ask, “What is it for? How is it taken? When is it taken? What side effects have you experienced? Have you ever stopped taking doses? Is there anything else you do not understand about the medication but would like to know?” When the client has a history of poor compliance, review resources available for the purchase of medications.

Client's Learning Needs

Determine the need for instruction by assessing the client's level of knowledge about a medication and the resources available to help the client to take medications regularly. You may need to explain the action and purpose of the medication, the expected side effects, the correct administration techniques, and steps the client can take to remember the medication regimen. If a client has a newly prescribed medication, your instruction will need to be more involved.

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BOX 34-9 CULTURAL ASPECTS OF CARE

Influences on Medication Administration

Health beliefs vary by culture and often influence how clients manage and respond to drug therapy. Differences in values, beliefs, and attitudes affect a client's compliance with drug therapy. For example, cultures attach different symbolic meanings to medications and drug therapy.

Herbal remedies and alternative therapies are common in some cultures and ethnic groups and can interfere with prescribed medications. In addition, differences between the health beliefs of health care professionals and their clients can affect a client's compliance with medical therapy.

Demographic changes in both age and race can affect the nursing practice in medication administration. In addition to the psychosocial aspect of medication therapy, pharmacological research has shown that some ethnic and racial groups experience differences in drug response, metabolism, and side effects.

Implications for Practice

• Assess a client's cultural beliefs, attitudes, and values when administering medications and teach clients about their medications.

• Resolve conflicts between medications and cultural beliefs to achieve optimal client outcomes.

• Ask whether the client practises any alternative therapies or takes any herbal preparations.

• If a client is not responding to drug therapy as expected, consider whether cultural influences affect the drug response, the rate at which it is metabolized, and side effects. Bear in mind that a change in the client's medication is sometimes necessary.

• Always exercise awareness of your personal beliefs and distinguish between your values and the clients'.

from Andrews, M. M., & Boyle J. S. (2007). Transcultural concepts in nursing care (5th ed.). Philadelphia, PA: Lippincott; and from McKenry, L. M., Tessier, E., & Hogan, M. A. (2006). Mosby's pharmacology in nursing (22nd ed.). St. Louis, MO: Mosby.

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Nursing Diagnosis

Assessment of the client provides data about the client's condition, the ability to self-administer medications, medication management (e.g., diabetic management), and medication use patterns, which can be used to determine actual or potential problems with medication therapy. Certain data are defining characteristics; when clustered together, they reveal nursing diagnoses. For example, noncompliance related to a medication regimen may be indicated when a client admits that he or she is not taking prescribed medications correctly, or when evidence shows that a medication has not reversed symptoms as expected. The following nursing diagnoses may be observed during the administration of medications:

• Anxiety

• Ineffective health maintenance

• Health-seeking behaviours

• Deficient knowledge of medications

• Noncompliance with prescribed medications

• Disturbed visual sensory perception

• Impaired swallowing

• Effective therapeutic regimen management

• Ineffective therapeutic regimen management

After the client's diagnosis has been selected, identify the related factors, which guide the selection of nursing interventions. For example, the related factors of inadequate resources and lack of knowledge require different interventions. If the client's noncompliance is related to inadequate finances, collaborate with the client's family members, social workers, or community agencies to ensure the client receives the necessary medications. If the related factor is lack of knowledge, initiate referrals to ensure home care nurses follow up with the client and that they implement an extensive teaching plan.

Planning

Organize care activities to ensure the safe administration of medications. Hurrying to give clients medications can lead to errors. When preparing and administering medications, it is important to minimize distractions and interruptions (Pape et al., 2005).

Goals and Outcomes

Setting goals and related outcomes will help you to use your time wisely during medication administration. For example, establish the following goal and related outcomes for a client with newly diagnosed type 2 diabetes:

Goal: The client will safely administer all ordered medications before discharge.

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Outcomes:

• The client will express an understanding of the desired effects and the adverse effects of medications.

• The client will state the signs, symptoms, and treatment of hypoglycemia.

• The client will be able to monitor and interpret blood glucose levels to determine medication management or treatment for hypoglycemia.

• The client will establish a daily routine that will coordinate timing of medication with mealtimes.

Setting Priorities

Prioritize care when administering medications. Use information gathered from your assessment of the client to determine whether the administration of medications is appropriate and, if it is, which medication should be given first. For example, if a client is in pain, provide pain medication as soon as possible. If the client is experiencing an elevated blood pressure, antihypertensive medications should be administered before other medications. Establish priorities when providing client education about medications. Provide the most important information about the medications first. For example, because hypoglycemia is a serious side effect of insulin, the client must be able to identify and treat hypoglycemia before learning how to administer an insulin injection.

Collaborative Care

Nurses collaborate with a variety of health care professionals when administering medications. It is also important when giving instruction to collaborate with the client's family or friends, who can reinforce the importance of medication regimens in the client's home setting. Interdisciplinary collaboration with the prescriber, the pharmacist, and the home care case manager helps to ensure the client receives medications safely. Ensure that clients are able to read both medication labels and printed teaching sheets. Collaborate with community resources (e.g., the home care nurse, social workers) if clients have difficulty in understanding medication management, adhering to medication routines due to functional ability, or accessing resources because of physical or financial restrictions.

When clients are hospitalized, do not postpone their medication and discharge instructions until the day of discharge. In order for the client to understand medications and self-administration guidelines, you must allow sufficient time for questions and discussion. Early planning is critical. Whether a client attempts self-administration or a nurse assumes responsibility for administering medications, the following goals and expected outcomes must be met: (a) the client and the client's family understand the medication therapy; (b) the client gains the therapeutic effect of the prescribed medications without discomfort or complications; (c) the client experiences no complications related to the route of administration; and (d) the client can safely self-administer the prescribed medications.

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Implementation

Health Promotion

When working with clients to promote and maintain their health, you need to identify factors that may improve or diminish their well-being. Beliefs about health, personal motivations, socioeconomic factors, and habits (e.g., smoking) can influence the client's compliance with the medication regimen.

Teaching the client and the client's family about the benefit of a medication and the knowledge needed to take it correctly is an essential component of primary health care and can promote adherence to the medication regimen (Box 34-10). Integrating the client's health beliefs and cultural practices into the treatment plan can assist in establishing a schedule or routine with the client. You may make referrals to community resources if the client cannot afford to purchase the necessary medications, or if the client cannot arrange transportation to obtain the necessary medications. You should teach all clients the basic guidelines for medication safety. These guidelines ensure the proper use and storage of medications in the home (Box 34-11).

Acute Care

Clients are often hospitalized to receive expert nursing observation and documentation of their responses to medications. When receiving a medication order, several nursing interventions are essential for safe and effective medication administration.

Receiving Medication Orders.

A medication order is required for any medication to be administered by a nurse. Before any other interventions, ensure the medication order contains all of the elements in Box 34-12. If the medication order is not complete, inform the prescriber and ensure completeness before carrying out the medication order.

BOX 34-10 FOCUS ON PRIMARY HEALTH CARE

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Improving Drug Compliance

When a client is discharged from hospital or sent home from a visit to a clinic, the ongoing treatment may include regularly taking medications at home. In cases of chronic illness, the success of the treatment may depend on the client's compliance with drug therapy. Nurses can play an important role in assisting clients to comply with their medication regimen.

The following suggestions may improve client compliance:

• Ensure that the client and the client's family understand the reason for the medication, proper administration of the medication, and the possible consequences of noncompliance.

• Ensure that the client and the client's family and friends are able to recognize symptoms of medication side effects or toxicity, such as physiological changes and alterations in behaviour. Because the client's family members and friends are often the first people to recognize such effects in the client, they are an important resource for ensuring client compliance.

• Teach proper self-administration of medications to clients for all routes. For example, demonstrate how to accurately measure a liquid medication. Show the client how to prepare and administer an injection correctly by using aseptic technique. Assess the client's ability to self-administer injections. If a client cannot independently self-administer injections, family members or friends can be taught to administer the injections. Alternatively, collaborate with community and home care services to administer injections when clients are discharged to their home. Provide specially designed equipment as necessary, such as syringes with enlarged calibrated scales for easier reading or Braille-labelled medication vials.

• Help the client to address any economic issues that might affect compliance.

• Explore with the client any factors that will influence his or her ability to comply; for some clients, keeping a daily medication log may be helpful.

• Provide a written schedule that includes the name of the medication, the dose, and a description or picture of the medication.

• Encourage clients to take their medication in conjunction with an activity they do every day, such as brushing their teeth or having breakfast.

• Help clients to organize their pills into a box with daily dividers. If compliance is a major concern, home care nurses or family members can check the box and refill it on a weekly basis.

• Work with the client's pharmacist to ensure the pharmacy calls to remind the client when a refill is required.

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Correct Transcription and Communication of Orders.

Nurses or a designated unit secretary sometimes write the prescriber's complete order on the appropriate medication form, the medication administration record. The transcribed order includes the client's name, identification number, room, bed number, allergies, and the medication name, dose, frequency, and route of administration. Each time a medication dose is prepared, refer to the medication form. When the unit-dose system is used, only one transcription is necessary, which limits the opportunity for errors. When transcribing orders, ensure that names, doses, and symbols are legible. Rewrite any smudged or illegible transcriptions.

Some institutions have prescribed order entry. The prescriber enters an order directly into the computer, which avoids the need for the transcription of orders. Computer interfaces transfer the order to the medication administration record, the pharmacy record, and the automated dispensing system. The computer printout may be used as the medication administration record (Figure 34-12).

Always check all transcribed orders against the original order for accuracy and thoroughness. If an order is incorrect or inappropriate, consult the prescriber. If you give the wrong medication or an incorrect dose, you are legally responsible for the error. Other health care professionals involved in the error are also legally responsible.

BOX 34-11 CLIENT TEACHING

Safe Insulin Administration

Objective

• The client will correctly administer subcutaneous insulin.

Teaching Strategies

• Instruct the client how to determine that insulin is not out of date.

• Instruct the client to keep insulin in its original labelled container.

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• Instruct the client to keep insulin refrigerated if necessary.

• Assess the client's visual acuity to ensure that the client is able to prepare the appropriate amount of insulin.

• Demonstrate how to rotate the location of insulin injection sites.

• Help the client to determine the amount of insulin required based on the results of home capillary glucose monitoring, as ordered by the client's health care professional.

• Observe the client's ability to correctly assess the results of capillary blood glucose monitoring.

• Demonstrate to the client how to prepare a single insulin preparation.

• Demonstrate to the client how to administer a subcutaneous insulin injection.

• Show the client how to keep a daily log book to record insulin injections, including results of home capillary glucose monitoring, type and amount of insulin given, expiration date on insulin vial, time of insulin injection, and injection site used.

Evaluation

• Ask the client to describe the signs and symptoms of hypoglycemia and the associated interventions.

• Ask the client to describe the procedure used at home for determining the correct dose of insulin needed and the injection site.

• Observe the client preparing an insulin dose on the basis of the results of capillary glucose monitoring.

• Observe the client selecting the injection site and self-administering the insulin injection.

• Review the information recorded in the client's log book for completeness.

BOX 34-12 Components of Medication Orders

A complete medication order includes all the following information:

• Client's full name: The client's full name distinguishes the client from other persons with the same last name. In an acute care setting, clients may also be assigned a special identification number (e.g., a medical record number) to help differentiate clients with the same names. This number may be included on the order form.

• Date and time the order is written: The day, month, year, and time must be listed. Designating the time that an order is written helps to clarify when certain orders are to stop automatically. If an incident occurs involving a medication error, documentation is easier when this information is available.

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• Medication name: The prescriber will order a medication by its generic or trade name. Correct spelling is essential to prevent confusion with medications with similar spelling.

• Dose: The amount or strength of the medication is included.

• Route of administration: The prescriber uses accepted abbreviations to indicate the medication routes. Accuracy is important because some medications can be administered by more than one route.

• Time and frequency of administration: Nurses need to know when to initiate medication therapy. Orders for multiple doses establish a routine schedule for medication administration.

• Signature of prescriber: The prescriber's signature makes the order a legal request.

Accurate Dose Calculation and Measurement.

When measuring liquid medications, use a standard measuring container to reduce the chance of error. Calculate each dose when preparing the medication, pay close attention to the process of calculation, and avoid interruption from other nursing activities (Pape et al., 2005). Consult with other nurses when calculating a new or unusual dose.

Correct Administration.

To help ensure safe administration, use aseptic techniques and proper procedures when handling and giving medications. Verify the client's identity by using at least two client identifiers (The Joint Commission, 2007) and perform the necessary assessments (e.g., assessing heart rate before giving antidysrhythmic medications). Carefully monitor the client's response to medication, especially when administering the first dose of a new medication. Document the client's response on the appropriate record forms.

Recording Medication Administration.

After administering a medication, record it immediately on the appropriate record form (see Figure 34-12). Never chart a medication before administering it. Recording the medication immediately after its administration prevents errors.

The recording of a medication includes writing the name of the medication, the dose, the route, and the exact time of administration. Record assessment parameters (e.g., blood glucose level, blood pressure, pain score) and the site of any injections, in accordance with agency policy.

If a client refuses a medication or undergoes tests or procedures that result in a missed dose, the reason why the medication was not given must be recorded in both the medication administration record and nurse's notes.

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Figure 34-12 Example of a medication administration record.

Restorative Care

Medication administration activities vary among the numerous types of restorative care settings. Clients with functional limitations may require you to fully administer all medications. In the home setting, clients usually administer their own medications. Regardless of the type of medication activity, you are responsible for instructing clients and their families in medication action, administration, and side effects. Additionally, you

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editionneed to monitor the client's compliance with medication and determine the effectiveness of medications that have been prescribed.

Special Considerations for Administering Medications to Specific Age Groups

A client's developmental level affects the way that nurses administer medications. Your knowledge of a client's developmental needs helps you to anticipate responses to medication therapy.

Infants and Children.

Children vary in age, weight, body surface area, and their ability to absorb, metabolize, and excrete medications. Children's medication doses are lower than doses for adults; therefore, special caution is needed when preparing medications for children. Medications are usually not prepared and packaged in standardized dose ranges for children. Preparing an ordered dose from an available amount of medication requires careful calculation.

All children require special psychological preparation before receiving medications. The child's parents are valuable resources for learning the best way to administer medications to their child. Sometimes the child will experience less trauma if a parent administers the medication and you supervise.

Supportive care is needed if a child is expected to cooperate. Explain the procedure to the child, using short words and simple language appropriate to the child's level of comprehension. Long explanations may increase the child's anxiety, especially for painful procedures such as an injection. You need to administer medications to children even when they refuse to cooperate or resist consistently despite explanation and encouragement. If the child is uncooperative, administer the medication to the child quickly and carefully (Hockenberry & Wilson, 2007). If you are able to involve the child, you may have greater success giving a medication. For example, when you say, “It's time to take your tablet now. Do you want it with water or juice?” you are allowing the child to make a choice. Do not give the child the option of not taking a medication. After a medication is given, praise the child; you may even offer a simple reward such as a star or a token. Tips for administering medications to children are listed in Box 34-13.

Older Adults.

Older adults also require special consideration during medication administration (Box 34-14). In addition to physiological changes of aging (Figure 34-13), behavioural and economic factors influence an older person's use of medications.

Polypharmacy.

Polypharmacy occurs when the client takes two or more medications to treat the same illness, when the client takes two or more medications from the same chemical class, when the client uses two or more medications with the same or similar actions to treat several disorders simultaneously, or when a client mixes nutritional supplements or herbal products with medications (Brager & Soland, 2005; Ebersole et al., 2004). Older adults also often experience polypharmacy when they self-medicate to seek relief from a variety of symptoms (e.g., pain, constipation, insomnia, and indigestion) by using over-the-counter (OTC) preparations, traditional folk medicines, or herbal remedies. Over-the-counter medications contain many

34.10.4

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Canadian Fundamentals of Nursing - Revised Reprint, 4th Editiondifferent ingredients; when used inappropriately, they can cause indesirable side effects and adverse reactions, or they may be contraindicated by the client's condition.

BOX 34-13 Tips for Administering Medications to Children

Oral Medications

• Use liquid forms when available. They are safer for children to swallow and they help to avoid aspiration.

• Use droppers to administer liquids to infants.

• If older childen have difficulty swallowing pills, suggest that they put the pill in their mouth and then sip liquid through a straw. The suction action pulls the liquid up the straw and makes it easier to swallow the pill.

• Offer juice, a soft drink, or a frozen juice bar after a medication is swallowed.

• To reduce nausea, pour carbonated beverages over finely crushed ice.

• When medications are mixed with palatable flavourings, such as syrup or applesauce, use only a small amount. Avoid mixing a medication with foods or liquids that the child enjoys because the child may in turn refuse them.

• A plastic, disposable syringe is the most accurate device for preparing liquid doses, especially doses of less than 10 mL (cups, spoons, and droppers are inaccurate.)

• When administering liquid medications, use a spoon, a plastic cup, or an oral syringe (without needle).

Injections

• Use caution when selecting IM injection sites for infants and small children. The deltoid muscle, which can be used for adults and older children, is underdeveloped and should not be used in infants and small children.

• Children can be unpredictable and uncooperative. Ensure that someone (preferably another nurse) is available to restrain a child if physical control is needed. The parent should act as a comforter, not a restrainer.

• Always awaken a sleeping child before giving him or her an injection.

• Distracting the child with conversation, a ringing bell, or a toy may reduce the child's perception of pain.

• Give the injection quickly and do not argue with the child.

• If time allows, use a eutectic mixture of local anaesthetics (EMLA) cream.

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BOX 34-14 FOCUS ON OLDER ADULTS

• Simplify the drug therapy plan whenever possible (McKenry et al., 2006).

• Keep instructions clear and simple and provide written material in large print (Ebersole et al., 2004).

• Assess the client's functional status to determine whether the client requires assistance in taking medications (McKenry et al., 2006).

• Have the client drink a little fluid before taking oral medications to ease swallowing. Encourage the client to drink at least 150—180 mL of fluid after taking medications (Ebersole et al., 2004).

• Older adults may have a greater sensitivity to drugs, especially drugs that act on the central nervous system. Therefore, you need to carefully monitor clients' responses to medications and anticipate dosage adjustments as needed (Meiner & Lueckenotte, 2006).

• If the client has difficulty swallowing a capsule or tablet:

• Ask the physician to substitute a liquid medication if possible (Ebersole et al., 2004).

• Ask the client to sit up straight and to tuck in the chin to decrease risk of aspiration (McKenry et al., 2006).

• Teach alternatives to medications, such as proper diet in place of vitamins and exercise in place of laxatives (Ebersole et al., 2004).

• On a frequent basis, review the client's medication history, including over-the-counter medications (Meiner & Luekenotte, 2006).

34.10.4.2.1.234.10.4.2.1.2



Figure 34-13 The aging body and drug use.

Source: From Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2004). Medical-surgical nursing (6th ed.). St. Louis, MO: Mosby.

Because many older adults suffer chronic health problems, polypharmacy is common. The client who experiences polypharmacy is at an increased risk of adverse reactions and medication interactions with other medications and food.

Polypharmacy can be divided into two types: rational polypharmacy and irrational polypharmacy. Rational polypharmacy occurs when clients need to take several medications to treat their health conditions, which is often the case for older adults. For example, many older adults take multiple medications to lower their blood pressure. Irrational polypharmacy occurs when the client takes more medications than needed. Irrational polypharmacy results from several causes. For example, some older adults need to see more than one health care professional to treat their different health conditions. When health care professionals fail to take an accurate medication history or do not communicate with each other, the result can be clients taking many different medications, which increases their risk of polypharmacy (Brager & Soland, 2005).



Noncompliance.

Noncompliance is defined as a deliberate misuse of medication, such as not taking a prescribed medication or altering the dose of a medication. In general, noncompliance occurs either because of drug ineffectiveness, uncomfortable side effects, or the prohibitive cost of the medicine.

Evaluation

Nurses monitor client responses to medications on an ongoing basis. For each medication, you require knowledge of the desired effect, the therapeutic action, and the common side effects. A change in a client's condition can be physiologically related to health status, medications, or both. Be alert for reactions in a client who takes several medications. To achieve the goal of safe and effective medication administration, a careful evaluation of both the client's response to therapy and the client's ability to assume responsibility for self-care is required.

To evaluate the effectiveness of nursing interventions in meeting established goals of care, use evaluative measures to identify whether client outcomes were met. Apply various evaluation measures in the context of medication administration, including direct observation of the client's behaviour or response, rating scales and checklists, and oral questioning. Physiological measurement is the most common method of evaluation. Examples of physiological measures are blood pressure, heart rate, and visual acuity. Client statements can also be used as evaluative measures. Table 34-9 gives examples of goals, expected outcomes, and corresponding evaluative measures.

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