Medication Administration

Michael Anthony D. Samaniego, RM, RN University of the Philippines Manila School of Health Sciences Extension Campus, Baler, Aurora

 Medication administered to clients are used, almost exclusively, to prevent, diagnose, or treat disease. Because medication administration and evaluation are essential to nursing practice, nurses need to know the actions and effects of medications they deliver to clients.

Pharmacological concepts
Drug names
A medication may have as many as 3 different names Chemical name provides an exact description of the medications composition and molecular structure. Generic/non-proprietary name official name of the drug that is listed in official publications like drug handbooks and in the drug package itself.

 Trade/Brand/Proprietary name the name under which a manufacturer markets a medication. It has a symbol , at the upper right indicating that the manufacturer has trademarked the medications name.
N acetyl para aminophenol (Chemical Name) Acetaminophen (Generic Name)

Tempra, Calpol (Brand Names)

Forms of Medications

Pharmacokinetics
The study of how medications enter the body, reach their site of action, are metabolized, and exit the body. Nurses use knowledge of pharmacokinetics when timing medication administration, selecting the route of administration, and observing clients responses.

Absorption
Refers to the passage of medication molecules into the blood form its site of administration. Factors influencing absorption:
Route of administration Ability of medication to dissolve Blood flow to the site of administration Body surface area Lipid solubility of a medication

Types of medication action

Therapeutic effects:
The expected or predictable physiological response a medication causes. Each medication has a desired therapeutic effect for which it is prescribed.

Example: nitroglycerine for cardiac workload reduction, aspirin for antiinflammatory, paracetamol for antipyretic.

Side effects
Are the unintended, secondary effects a medication predictable will cause. Side effects may be harmless or injurious. If the side effects are serious enough to negate the beneficial effects of a medications therapeutic action, the prescriber may discontinue the medication. Clients usually stop taking medications because of the side effects.

Adverse effects
Generally considered severe responses to medication. For example: a client may become comatose when a drug is ingested. When adverse responses to medications occur, the prescriber must discontinue the medication immediately. Some adverse effects are unexpected effects that were not discovered during drug testing.

Toxic effects
May develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Example: toxic levels of morphine, an opiod, may cause severe respiratory depression or death. Antidotes are used to treat specific types of medication toxicity.

Idiosyncratic reactions
Happens when a client overreacts or underreacts to a medication or has a reaction from normal. Example: a patient taking antihistamine may become extremely agitated or excited instead of drowsy.

Allergic reactions
Unpredictable response to a medication. May be mild or severe Allergic symptoms include:
Sudden bronchial constriction Edema of pharynx and larynx Wheezing and shortness of breath

Antibiotics have the highest cases of AR Antihistamines, epinephrine, and bronchodilators may be used to treat severe AR

Medication interactions
Occurs when one medication modifies the action of another Common in individuals with multiple medications Interaction may potentiate or diminish the action of other medications

Synergistic effect: the effect of two medications combined is greater than the effect of medications given separately. Example: alcohol and antihistamine

Routes of administration
Depends on the medications properties and desired effect and on the clients mental and physical condition. Oral routes
Easiest and most commonly used Given by mouth and swallowed with fluid Have slower onset of action and a more prolonged effect than parenteral medications. Most preferred route.

Medication actions
Onset time it takes after a medication is administered for it to produce a response. Peak time it takes for a medication to reach the highest effective concentration Through minimum blood serum concentration of medication reached just before the next scheduled dose Duration time during which the medication is present in concentration great enough to produce a response Plateau blood serum concentration of a medication reached and maintained after repeated fixed doses.

Oral routes
Sublingual
Readily absorbed after being placed under the tongue to dissolve Should not be swallowed, or the desired effect will not be achieved. Nitroglycerine is an example Placing the solid medication in the mouth and against the mucous membranes of the cheek until the medication dissolves Client must alternate between cheeks to prevent irritation Do not chew or swallow medication or take any liquids with it.

Buccal

Parenteral routes
Involves injecting a medication into body tissues. Intradermal into the dermis just under the epidermis Subcutaneous into tissues just below the dermis of the skin Intramuscular into a muscle Intravenous into a vein

Epidural administration
Medications are administered in the epidural space via a catheter. Done by a nurse anesthetist or anesthesiologist Commonly used for analgesia postoperatively

Intrathecal
Administered through a catheter that has been placed into the subarachnoid space or into one of the ventricles of the brain. Associated with long-term medications through catheters that have surgically been implanted Usually physicians do this

Topical administration
Medications applied to the skin and mucous membranes and generally have local effects Systemic effects may occur if the skin of the client is broken down
Includes ointments, eye drops, gargles, suppository

Inhalation
Medications administered through the nasal passages, oral passages, or endotracheal or tracheostomy tubes. Readily absorbed and work rapidly because of the rich vascular alveolar capillary network available Can either have local or systemic effects

Intraocular
Delivery includes inserting a medication similar to a contact lens into the clients eyes The disk can remain in the eyes up to one week Usually includes medications for eye problem treatment like glaucoma.

Types of Order
Standing order/ Routine medication orders
Carried out until the prescriber cancels it by another order or until a prescribed number of days elapsed. May indicate a final date or number of treatment or doses. Example:
Tetracycline 500mg PO q6h Decadron 10mg daily x 10 days

PRN orders
Prescribed when a client requires the medication The nurse uses objective and subjective assessment and discretion in determining whether or not the client needs the medication Example:
Morphone sulfate 2 mg IV q 12 h prn for incisional pain

The nurse should always document the assessment made and the time of administration

Singe (one-time) orders

Prescribed to be given only once at a specified time Common for preoperative medications or medications given before diagnostic examinations
Example:
Ativan 1 mg IV on call to MRI Valium 10 mg PO at 0900.

STAT orders
Signifies that a single dose of a medication is to be given immediately and only once Often written for emergencies when the clients condition changes suddenly
Example: Give Apresoline 10 mg IV STAT

Some conditions change the clients medication orders, such as surgery when all pre-operative medications must be cancelled after the operation. New orders must be written

Prescriptions
Written for clients who will take medications outside the hospital More detailed information than a regular order to foster understanding Includes:
Clients name, Rx, drug name, strength and dose, signature and name of the prescriber

Medication error
Any event that could cause or lead to a client receiving inappropriate medication therapy or failing to receive appropriate medication therapy. Usually occurs when nurses are distracted or fails to follow routine procedures such as checking dose calculations, etc

Ways to prevent medication errors

Read medication labels carefully Question administration of multiple tablets or vials for single dose Be aware of medications with similar names Check decimal point Question abrupt and excessive increase in dosages When new or unfamiliar medication is ordered, check a reference Do not administer medication ordered by nickname or unofficial abbreviation

 Do not attempt to decipher illegible handwriting Know clients with the same last names. Also, have clients fully state their names and check bands carefully. Do not confuse equivalents

Avoiding Medication Errors

Follow the 10 Golden rules of Drug Administration

1.

RIGHT DRUG - ensure that the medication order is properly composed and includes;

Patients full name Drug name Dosage form Dose amount Administration route Time schedule Practitioners signature Date and Time of order

Check the medication order against drug label THREE TIMES (3X) Know why the patient is receiving the specific drug at this time. Do not administer a medication someone else has prepared If using a unit dose system, do not open the packaging until you are at the client's bedside Never leave a medication unattended

2.) RIGHT ROUTE

Check the order and medication supplied Oral (by mouth or gastric tube) Parenteral ( ID, Subcutaneous, IM, IV) Topical Otical Opthalmic Mucous membrane ( sublingual, buccal, vaginal, rectal, intranasal, transdermal, inhalation)

Primarily for local effects

Topical application- to mucous membranes or skin

Intra-articular- within a cavity of a joint

Intracardiac- into a chamber of the heart Intradermal or intracutaneous- into the dermal layer of the skin Intrathecal- into the spinal fluid Inhalation- into the respiratory tract

Primarily for systemic effects

By the gastrointestinal tract:
Buccal or transmucosal -in the cheek Oral- by mouth Sublingual- under the tongue Rectal- in the rectum

 By injection: Intramuscular- into a skeletal muscle

Intraosseous- into the bone marrow

Intratracheal- into the trachea Inravenous- into a vein

Subcutaneous- into the subcutaneous tissue

3.) RIGHT DOSE- perform dosage calculation always use the appropriate measuring device and read it correctly ( measure liquid for oral administration at the meniscus) shake all suspensions and emulsions when measuring drops of medication with a dropper, always hold the dropper vertically and close the medication cup

 when removing a drug from a multiple dose vial, inject an amount of air equal to the amount of fluid to be withdrawn do not attempt to divide unscored tablets and do not administer tablets that have been broken unevenly along the scoring

4.)RIGHT TIME verify the frequency of dosage with the medication order 5.) RIGHT PATIENT

check the tag on the client's bed check the client's identification band ask the client to state his name ask the parents to state the name of their child always check a prescription that the client questions

6.) RIGHT DOCUMENTATION

Make sure that the practitioners order is clear and complete Compare the original order with the medication label to ensure accuracy Record the medication in the patients chart immediately after administering it If the patient doesnt take the medication, document that the drug was not given, why; notify the practitioner if appropriate.

7.) RIGHT EDUCATION Teach your patient about the drug he is receiving 8.) RIGHT DRUG HISTORY take a complete patient drug history (there is a risk of adverse drug reactions when a number of drugs are taken or when patient is taking alcohol drinks)

9.) RIGHT TO REFUSE be sure to assess the client's reason for refusing the medication document if client refuses medication, client's reason and reporting of refusal to healthcare provider Do not forget to assert client education as to why is the medication prescribed, what the medication does, and importance of medication for treatment of client's health alteration.

10) Find out if the patient has any drug allergies Be aware of drug-drug, drug-food interactions.

To protect your patient and your license, follow these guidelines for avoiding medication errors.

Standards
Those actions that ensure safe nursing practice Six rights of medication administration
The right medication The right dose The right client The right route The right time The right documentation

Right medication
Checking and verifying the prescribers orders by checking the chart and the medication container
Before removing the container from the drawer or shelf As the amount of medication ordered is removed from the container Before returning the container to storage

Nurses administer only those medications that they prepared If error occurs, the one that administered the medication is liable

Right dose
Ensuring that the right amount of medication is given to the patient. Minimize errors by carefully calculating the dose, using appropriate measuring tools (dropper, teaspoon, etc)

Right client
Identify a client correctly by checking the clients identification bracelet and letting the client state his/her name. Let the parent of a child patient state the name of his/her daughter or son.

Right route
If the route is not included in the order, the nurse must consult the prescriber. Ensure that medications are given properly especially with administering injections

Right time
The nurse must know why a medication is ordered for certain times of the day Preferably, medications must be administered during waking hours Medications that must act at certain times are given priority; example insulin after meals PRN medication requires the nurses clinical judgment in determining time of administration.

Right documentation
It is an important part of safe medication administration Should reflect all information such as name of the client, ordered medication, time, dosage, route, frequency. The nurse should put her initials in the chart after administering the medication

Nursing Process in Drug Administration

 Assessment
History History of allergies Medication data Diet history Clients perceptual or coordination problem Clients current condition Clients attitude about medication use Clients knowledge and understanding of medication therapy Clients learning needs.

Assessment

Determine whether the patient has food or drug allergies; document clearly on the patients chart all food and drug allergies.

Find out:

Which prescription and non-prescription medications the patient currently takes The frequency of administration Whether the patient has experienced adverse effects

Obtain history of the patients medical conditions , socioeconomic status, and psychosocial support.
Perform a physical examination; pay particular attention to body systems that may be affected by current or newly prescribed medications or to areas where the patient has complaints or concerns.

Nursing Diagnosis

Develop a Nursing Dx consisting of the patients disease and its etiology. Begin addressing problems that pose immediate threats to the patients threats Commonly listed nursing diagnoses related to drug administration include:

Deficient knowledge Risk for injury Ineffective therapeutic regimen management Non-compliance

Planning

Develop outcomes using the diagnosis; if possible, obtain input from the patient and his family.
Use these goals as outcome criteria for evaluation

Implementation

Put the care plan into action

Include all relevant nursing interventions, including drug therapy to meet the patients healthcare needs

A multidisciplinary team approach is usually needed

Ensure cleanliness of your hands, work area, and supplies Ensure availability of supplies Ensure adequate lighting Decrease environmental distractions

Evaluation

Evaluate whether interventions enabled the patient to achieve the desired outcomes Include appropriate evaluation statements, such as:

The patient experiences expected effects of the prescribed medication The patient avoids adverse effects or interactions with other drugs, foods or alcohol The patient demonstrates an understanding of information taught

The patient complies with the therapeutic regimen ( if the patient doesnt comply, determine the reasons for non compliance) Therapeutic drug levels are maintained

Based on patient evaluation, modify outcomes and interventions as needed.

Pregnancy Categories

Category A adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy and there is no evidence of risk in later trimesters

Category B Animal Studies have not demonstrated a risk to the fetus but there are no adequate studies in pregnant woman, or animal studies have shown an adverse effect , but adequate studies in pregnant women have demonstrated a risk to the fetus during the first trimester and no evidence of risk in later trimesters

Category C Animal studies have shown an adverse effect on the fetus but there are no adequate studies in human; the benefit of the use of the drug in pregnant women may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans.
Category D there is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant woman may be acceptable despite its potential risks

Category X

studied in animals and humans demonstrates fetal abnormalities or adverse reaction; reports evidence of fetal risk. The risk of use in a pregnant woman clearly outweighs any possible benefit.

Regardless of the designated Pregnancy Category or presumed safety, NO drug should be administered during pregnancy unless it is clearly needed