Lecture 2NUR 307Juan M Gonzalez BSN, RN

Drug Administration Nurses have a duty to protect their

patients Administration of medications is a large

part of what nurses are responsible for Just because it’s ordered does not mean

that we can’t question it Patient safety will ALWAYS come first Remember, the 1st way a nurse can kill a

patient is with drugs

Nurses’ Responsibilities Nurses are responsible and held

accountable for all medications they administer

You must know the drugs before you give them

Just knowing a part of a medication is not enough

If you don’t know it.. DON’T GIVE IT

What do I need to know?? Trade and generic name Classification Intended use & therapeutic effect Contraindications & special consideration Dose ranges & safety Expected side affects Adverse reactions

How to intervene for them

What else do I need to know? Your patient

Why are they taking it? Do they need it? What has your assessment revealed? What are you responsible for? Is this safe? Is it beneficial?

Bad, Bad, Bad Toxic Epidermal Necrolysis

Sloughing off Stevens-Johnson Syndrome

1-14 days Do they have a cold?

Anaphylaxis Can’t breathe

Allergic reaction Itchy

Be RIGHT all the time Right Patient Right Med Right Dose Right Route Right Time Right to Refuse Right Documentation Right to Know/Be Informed/Education Right Indication

Three Times’ the charm! Your not Santa- check it # times!!!

MAR Preparation Administration

No More UH-OHs Preventing Errors in Medication

Have complete information about the patient, including allergies

Be current on medication warnings Appropriate labeling of medications Avoid distractions

Ways of Noncompliance Not taking the medication Taking it on a different schedule Changing the dose &/or times Taking too much of it Not following dietary guidelines

Many meds have food and fluid restrictions Many need to be taken on an empty

stomach

Orders & Times Orders

STAT, immediately, now, single, repeat, prn Standing, routine, pre-med

Times BID, TID, QID 2X, 3X,4Xs daily Typically times start @ 9am

Abbreviations See chart page 20

Common Effects & Interventions

Drowsiness Switch from day to evening dosing Teach safety

No driving, fall precautions Nausea

Take with food or small snack Absorption interference

Take in-between meals

Measurements Metric

Safest one to use Memorize this one

Apothecary/Household Officially on the ‘do not use’ list Only focus on the teaspoon & tablespoon

equivalents

Routes Enteral

PO (oral) NG (nasogastric tube) GT (gastrostomy tube)

Topical Cream or fluid

Parenteral Uses a needle to deliver the drug

Enteral Tablets & caplets

Watch for 1st-pass problem Inactivated before they can do their job

Enteric coating- don’t crush Time released- don’t crush

SR, XR, LA Sublingual

Under the tongue Buccal

Between gum & cheek NG/GT

Meds must be crushed or in liquid form

Topicals Creams

Most common Vary in texture Used for the local effect OR systemic condition

Need to know which one and why Patches

Make sure the old one is off Rotate sites

Liquids Flushes, irrigation, drops

Inhalants Rapid onset

Parenteral Intradermal (ID)

Allergy shots Subcutaneous

Insulin, Heparin, vaccines Intramuscular (IM)

Pain meds, anti-infectives Intravenous (IV)

Directly into the bloodstream

Errors Preventable National Coordinating Council for

Medication Error Reporting and Prevention (NCC MERP)

#1 cause of preventable patient morbidity & death

NO acceptable rate (%) of errors

Reporting Errors At the Federal Level (FDA) MEDWATCH (1992) NCC MERP (1995) Reporting errors will also help others

avoid making similar mistakes Safety 1st

Documenting Errors Every facility has a policy & procedure Must include what was done about the

error (VS, labs, antidote) List who was notified Incident Reports Sentinel Event

Categorizing Errors Categories A-I Category A- No actual error Category B-D- Error, no harm Category E-H- Error,harm Category I- Error, DEATH

See page 89, figure 9.2

Reduction/Prevention Risk Management Education

Patient Staffing

Big Brother Government & other agencies are in

place to track errors FDA’s safety administration & adverse

event reporting program (MEDWATCH) Institute for Safe Medication Practices

(ISMP) MEDMARX

Anonymous reporting program (hospitals)

ANTHRAX Bioterrorism Agent Carried by ‘hoofed’ animals Can be spread a variety of ways ‘spores’ S/S appear with 1-6 days of exposure Manifestations depend on how it was

acquired

Manifestations of AnthraxTYPE DESCRIPTION SYMPTOMS

Cutaneous Most commonOpen woundCurable if Tx within 1st few weeks

Skin lesion turn into black scabsCan’t be spread person-to-person

Gastrointestinal Rare, ingestedLethal (50%)- if not Tx

Sore throat, swallowing probs, cramps, diarrhea, abdominal swelling

Inhalation Least commonMost dangerousMust be Tx within days

1st- fever, fatigueThen SOB, CoughDeath within 4-6 days

Anthrax Treatment Ciprofloxacin

Over-use leads to resistant strains Minimize Rx Only given if proven contamination

Vaccine Not 100% proven Limited to those with high risk of exposure 3 injection at 2 week intervals, then 3 more

injections at 6, 12, and 18 months Yearly booster

Using the Nursing Process in Pharmacology

The 5 Steps of the Nursing Process Assessment Diagnosis Planning Intervention Evaluation

The Nursing Process in Pharmacology

The nursing process guides decisions about drug administration to ensure patient safety and to meet medical and legal standards.

Assessment On-going Begin with a baseline assessment

To have measurements that you can determine effectiveness of treatment

Includes objective & subjective data Anything & everything that is pertinent

needs to be addressed Systematic approach

Subjective Data Always in “” quotes From the patient, family, staff, or chart Subjective means words stated Examples:

“I don’t feel well” Chart states “combative” MD reported “pt noncompliant with

regimen initially”

Objective Data Concrete Measurable Diagnostics Physical Findings Behavior Disease History: age, smoking/alcohol,drugs

Objective Data Examples Vital Signs Behavior

Grimacing Crying

Labs Drug levels Electrolytes

Disease Cardiac Asthma

History Smoker Alcoholism

Physical Findings Crackles in lungs 2+ pitting edema in lower extremities bilaterally

Labs Levels

Therapeutic vs Toxic range System Function

Renal BUN, creatinine, Na, K, etc

Hepatic Liver enzymes LFTs

Cardiac Enzymes BNP, LYTES

Pulmonary

Assessment On-Going New findings Therapeutic Benefits Adverse Effects/Side Effects How will they continue taking the med Financial constraints Transportation

To/From For labs

Other Assessment Data Any other medications

OTC Herbal Rx PRN ALL meds Allergies & Sensitivities

Including foods

Nursing Diagnosis NANDA defines Based on your assessment findings Should encompass all medications If there’s a med, there’s a Nursing Dx Patient Focused

Not about you (U)

PLANNING Establishing Goals & Outcomes This where we begin prioritizing,

formulating outcomes (goals), and selecting interventions to reach the goals

Goals Long-term: within the lifetime Short-term: within a few days

Outcomes: Objective measurements

Goals (Examples) Long-term

The pt will maintain adequate oxygenation =< 98% by the end of 6 weeks

Short-term The pt will have an increase in oxygenation

levels from 90% to 95% by May 26th Outcomes

The pt will demonstrate correct use of the incentive spirometer 2x shift

Planning & Pharmacology Medication Administration

Overall goal: Safe & effective administration of medication

Patient Education Overall goal: Patients comprehend the

purpose of every medication, the correct way it is to be administered, and what to do if problems arise.

Implementation/Intervention Putting the plan into action This is what you will be doing for the patient It is specific

Includes not only what, but how, when and where

This is how we ‘care’ for our patients It’s a ‘List of Directions” ANY nurse should be able to read and follow

this, not just you

Implementation/Intervention Monitoring the medications

Effects of Side effects/adverse effects Compliance Therapeutic benefits Objective data: vs, labs, relief of s/s Education Scheduling on-going assessments

Evaluating Effects Comparing current status to baseline Using the established goals/outcomes Reassessing and revising goals and plan Re-evaluating priority Using findings to revise the plan, or to

move on to another priority if resolved

Anthrax Plan of Care example

Is it Anthrax? What form? What s/s is the patient exhibiting? What does the patient tell you? What objective data do you have? What other information do you need?

Anthrax Plan of Care example

What test determines it is anthrax? Inhaled? Contact? Difficulty breathing? Cold s/s? In pain? Having trouble breathing? VS, CXR, lab results? How long has it been? What have they tried

to help it? Did it help? Do they know how they were exposued?

Anthrax Plan of Care example

Depending on what s/s the patient is exhibiting and what form of anthrax they were exposed to.

Will include a medication regimen with cipro, and possibly other medications in combination to alleviate s/s and treat the exposure.

Anthrax Plan of Care example

Depending on what s/s the patient is exhibiting and what form of anthrax they were exposed to.

Will include a medication regimen with cipro, and possibly other medications in combination to alleviate s/s and treat the exposure.

Anthrax Plan of Care example

For the purpose of this course, we will only focus on those interventions that apply to meds

Cipro is an anti-infective We would be certain to include actions of

assess benefits and any adverse effects

Anthrax Plan of Care example

For the purpose of this course, we will only focus on the goals that apply to meds

Is the patient displaying s/s of improvement by taking the medication

Look at VS, labs, etc Is the patient having any side effects? Has the medication done what it needed to do? Is the situation resolved, or do we modify or

continue the plan?