Nursing Management of Clients with Stressors Requiring Medication

AdministrationRegulatory Needs

Pharmacology PrinciplesThe Nurse’s RoleNUR101 Fall 2008

K. BurgerLecture # 10

PPP by:Sharon Niggemeier RN, MS (J. Garnar & R.Kolk)Revised 1006,1007 KBurger

Pharmacology Pharmacology: is the study of chemicals/drugs and

their effects on living organisms. • Drugs (legal and illegal) are chemicals intended

to elicit a specific effect.• Drugs alter physiological functions in the body,

they do not create a new function in a tissue or organ.

• Drugs also create unwanted effects in addition to the desired effect.

Terminology• Pharmacotherapeutics: use of drugs to treat or

prevent disease. It can be preventative, palliative, or restorative. “Why a drug is prescribed”.

• Pharmacokinetics: (means "drug movement") the study of the concentration of a drug during the processes of absorption, distribution, biotransformation (metabolism), and excretion of a drug. “What the body does to the drug”

• Pharmacodynamics: study of the mechanism of drug action on living tissue at the cellular level. “What the drug does to the body”

NCLEX Time

A nurse administering medications has many responsibilities. Among these responsibilities is a knowledge of pharmacokinetics. Which statement is the best description of pharmacokinetics?

• A.The passage of medication molecules into the blood from the site of administration

• B.The degree to which medications bind to serum proteins, which affects distribution

• C.The study of how medications enter the body, reach their site of action, metabolize, and exit the body

• D.The method by which a medication, after absorption, is moved within the body to tissues, organs, and specific sites of action

Nursing Responsibilities:Remember that drugs can help

or harm

• Nurses are liable for their actions, omissions, and for those duties they may delegate to others.

• They are personally responsible…legally, morally and ethically…for every drug they administer.

Nursing Responsibilities• Obtaining current knowledge base of drugs • Referring to authoritative sources in professional

literature (PDR, journals, etc.) (less than 5yrs old)• Questioning a drug order that is unclear or that appears

to contain an error• Refusing to administer a drug if there is a reason to

believe it will be harmful.• Performing correct techniques and precautions• Monitoring client response and documenting drug effects• Patient and family education

Nursing Process & Drug AdministrationASSESSMENT – Thorough collection of data• Information about the medication

Action – side effects – appropriate doseAge specific considerations – routes

• Information about the clientWhat other medications are they takingAllergies or other problems w/ medsGag reflex – Impaired swallowingDietary and/or Fluid restrictionsCultural and/or religious influencesGenetic factorsVital signsLab values – renal & liver function / protein & albuminAge Pregnant/breast feeding

Nursing Process & Drug Administration

Assessment: Pt needs to take meds, can’t swallow

• The result of this assessment is the NURSING DIAGNOSIS

• PLANNING: include goals that directly relate to the nursing diagnosis and specific outcome criteria (goals)

Nursing Process & Drug Administration

IMPLEMENTATION• Using correct techniques of preparation and

administration to deliver medications safely.

• Monitoring the client for therapeutic and non-therapeutic effects of the drug

• Client education for safe and accurate self-administration of the drug.

EVALUATION of the nursing care provided based on the level of achievement of the outcome criteria.

Critical Thinking The nurse is preparing to administer prescribed

antibiotics to an adult hospitalized client suffering from a wound infection. When the nurse offers the oral medication to the client, he says “ I’m not taking those. Pills make me gag and throw up.” Write a nursing diagnosis that addresses this problem.

Impaired swallowing R/T sensitive gag reflex AEB client reports gagging and vomiting when attempting to take oral medications

Critical Thinking

Write an outcome statement for your diagnosis.

Client will receive appropriate medication therapy without discomfort or vomiting.

Critical Thinking

What are some interventions for this problem?

Determine availability of alternate oral forms: liquid

If not contraindicated, crush medications and mix with applesauce for administration

Critical Thinking

How will you evaluate this process?

Is client able to take medications in liquid or crushed form without discomfort?

Is the therapeutic effect of the medication evident ( ie: C & S -, no S/S of infection)?

Has the client experienced any adverse effects of the medication?

Legal Aspects of Pharmacology

Purpose and Scope of Legal Controls:

• Protect public health and safety

• Laws govern testing, production, distribution, prescription and the administration of drugs.

Federal Medication Laws

1906 Pure Food & Drug Act Disclosure of dangerous ingredients

1912 Sherley Amendment No fraudulent claims of action

1914 Harrison Narcotic Act Established regulations for narcotics

1938 Food,Drug,CosmeticAct Drugs must be tested and proved safe

1952 DurhamHumphrey Amendment Established list of drugs needing RX

1962 Kefauver-Harris Amendment Drugs must be proven effective

1970 Controlled Substances Act Strict controls on distribution

1978 Drug Regulation Reform Act Shortened drug investigation time

Controlled Substance Act • Designed to promote treatment and prevention of drug

dependence• Established controls such as:

-Prescribers are registered with the DEA. A registry number is issued to each person and is renewed annually.-Complete written records of all drugs prescribed must be kept for two years. Pharmacists record each sale in triplicate. Schedule II drug prescriptions cannot be renewed.-DEA (Drug Enforcement Agency) monitoring

-Health care agencies must establish policies to comply with Federal law.-All units have a record of every controlled drug on the unit and two nurses at the change of every shift count all drugs.-All controlled drugs are stored using a double lock system. Keys to medication areas are under the control of nurses on the unit. -Discarding of controlled substances must be witnessed by another nurse-Written renewal orders are required every 72 hours for narcotics and schedule II & III drugs.

Controlled Substance Act - continued

Control Schedule

Drugs with a significant potential for abuse

are classified into 5 categories or schedules:

Schedule I: highest potential for abuse Illicit drugs (Heroin, LSD, Marijuana)

Schedule II: (Morphine, Dilaudid)

Schedule III: (Vicodin, Meperidine)

Schedule IV: (Valium, Xanax)

Schedule V: lowest potential for abuse (OTC cough suppresant w/codeine)

Drug Information Resources • The United States Pharmacopoeia ( USP)

and the National Formulary(NF) are highly recommended for use in agencies for all health care professionals to use as a resource.

• Agency pharmacists are an appropriate resource for obtaining drug information on the job.

•  Nursing drug handbooks: contain drug information along with nursing considerations.

Drug Information Resources-continued

• Physician's Desk Reference (PDR) Contains manufacturer's descriptions (package inserts) which are written using FDA standards, but may be slanted in favor of the drug being described.

• Package Inserts: Required by law for insertion with each new drug and must include a description, indications, precautions, dosage, and contraindications.

•  Electronic databases and Internet  

  

Medication Orders

• Two ways to obtain legal drugs:

• Prescription (Rx)- order written authorizing patient to receive medication.Prescriptions taken to pharmacy whereby the pharmacist dispenses the drug.

• Over the counter (OTC)- patient treats self and doesn’t need a prescribers order. Buys medications where ever they are available (Walmart, 7-11, etc.)

Prescriptions

• Written, legible prescriber’s order includes:

• Patient name

• Drug name

• Dose

• Route

• Frequency

• Date

• Signature

Types of Medication Orders

• STAT order: needed immediately

• Single order: given only once

• PRN order: given as needed

• Routine orders: given within 2 hours of being written and carried out on schedule

• Standing order: written in advance carried out under specific circumstances.

Drug Nomenclature • Chemical name: Precisely describes the chemical

& molecular structure of the drug.

• Generic name: Pharmaceutical name given by the US Adopted Names Council. This name is the same for every drug company.

eg. ibuprofen• Proprietary or Trade or Brand name:can be

copyrighted,popular name of the drug supplied by the manufacturer, easy to pronounce and easy to recognize.

eg. Advil, Motrin

Look at your drug guide sample

• What is the generic name?

• What are the various trade names ?

• What do you think about this drug's various trade names?

 

Example for the drug Demerol

• Chemical name: N-methyl 4 carboxypiperidine hydrochloride

• Generic name: Meperidine• Trade name: Demerol

• Brand name versus generic drug: Is the drug effect identical?????????

 

Drug Classifications

Drugs can be classified various ways:

• Therapeutic: categorizes drugs by the disease state they are used to treat.

• Pharmacologic: categorizes drugs by their mechanism of action

• Controlled Substance Schedule• Pregnancy Schedule

ExampleDrug Classifications

Therapeutic Classifications Anti-hypertensives Analgesics

Pharmacologic Classifications Diuretics Beta-blockers Vaso-dilators

Non-opioids Opioids Non-steroidal anti-inflammatory agents

Look at your drug guide example

• What is the Therapeutic classification?

• What is the Pharmacologic classification?

• Is it a controlled substance?

• What is the Pregnancy category?

Standards for Drugs • Purity: Must be physically pure in that it only

contains the ingredients stated.(very few drugs are available in a truly pure state – THINK…what impact might this have on drug administration?)

• Potency: Strength of the drug, measured by standardization of weight of ingredients.

• Bioavailability: The degree to which a drug can reach its site of action in the body.

Standards for Drugs • Efficacy: The effectiveness of the drug in

achieving the desired biological change.  

• Safety: The frequency and severity of adverse drug reactions (ADR) determines safety. No chemical is free of adverse effects.

• Investigational drugs: chemicals tested which may have potential as a new drug.

Drug Approval Process

• Pre-clinical testing on cells an animals

• Clinical testing in (4) phasesI – small # of healthy peopleII – small # of people with the diseaseIII – large # of people with the disease(marketing can occur after phase III)(new expedited process allows after phase II)IV – post marketing; voluntary

Types of Drug Preparations • Drugs are prepared in several drug forms

depending on the route of administration or the use that will be made of the drug.

• A variety of drug forms provide some flexibility in the administration of drugs. Examples: capsules, elixir, tablets, gel caps, powders, solutions, ointments, sprays,etc.

Essential Elements of Drug Knowledge for Nurses

• drug name(s): Locate in drug reference books, call pharmacist to clarify when a multitude of names for drugs causes confusion.

• drug classification: Note the classification it provides a general view of drug as an indicator of specific drug traits. i.e. “Antipsychotics”

• indications: why is this drug given? pain relief? tachycardia? combat infection?

Knowledge Guidelines• drug action: what is the drug supposed to do? • usual dose: range will vary with age, weight,

gender and method of administration. • route of administration: what is the preferred

route• desired effects: what is the therapeutic effect• side effects: predictable symptoms that occur as a

consequence of overall drug effects in the body. Can be mild (nausea, rash) or severe/life threatening (liver toxicity, blood dyscrasias) 

Knowledge Guidelines• untoward effects: dose related symptoms occur as

dose is too high = Adverse Drug Event (ADE); or idiosyncratic symptoms – opposite of therapeutic effect.

• interactions with other drugs: do they potentiate drug action (additive effect) or inhibit drug action (antagonistic effect) or otherwise incompatible

• interactions with food: may delay absorption, may combine with active ingredient and inactivate it.

• precautions: when does a special condition affect the decision to use the drug?

 

Knowledge Guidelines

• contraindications: what conditions are adversely affected by this drug?

• nursing implications:. List assessments to be made and guidelines to be taken

• pregnancy safety: pregnancy risk categories have been established to identify the risk to the fetus (teratogenic effect). The categories range from A(no risk), B, C, D, or X (should not be used ever).  

Knowledge Guidelines• patient/family education: teach patient necessary

information related to medication administration• Be sure to answer questions and emphasize

important points!• Some health care facilities have computer printout

on drugs that can be given to patients before discharge.

• MOST ESSENTIAL:Why does this patient need this drug?

 

Use your drug guide sampleto evaluate this Case Study

Your 72 y.o. client, who was admitted for dizziness leading to a fall, has been diagnosed with hypertension. The MD has added Lasix 40 mg p.o. b.i.d. as well as Calan SR (antihypertensive) 120 mg p.o. daily to the client’s original medication regimen of Digoxin 0.125 mg p.o. daily.

•What therapeutic effect is the MD expecting from the Lasix?•What, if any, precautions should the nurse be aware of regarding administration of Lasix to this client?•Is this an appropriate dosage?•What are the important nursing implications – assessment, implementation, client teaching for administration of this drug?

Rights of Drug Administration

The (5)? Rights offer guidelines for safe drug administration:

• Right patient• Right medication• Right dose• Right route• Right time• Right documentation• Right REASON• Right of client to refuse

Standard Abbreviations

• CHECK JCAHO Official Do Not Use List @ www.jcaho.org

• Review SCCC NUR101 Lab Worksheet

• CHECK ISMP List of Error-Prone Abbreviations, Symbols and Dose Designations @ www.ismp.org

Incorporating Lab Values

• Medications may be prescribed based on lab results

• Medications may alter body functioning and lab values may denote this

• Nursing responsibility includes incorporating lab data with medication administration

Some beginningNormal Lab Values to KNOW

• Fasting Blood Glucose 60-110

• Potassium (K) 3.5-5.0

• Albumin 3.5 – 5

• WBC 5000 – 10,000

• BUN 10-20

• Creatinine 0.5 – 1.2

The Case Study - continued

• Prior to administering the Lasix, the nurse checks the lab values of the client which are:

K 3.7 / Albumin 3.0 / BUN 28 / Creatinine 0.4

What is the NEXT action the nurse should take? Why?

Drug Calculations• Unit dose system, less need for calculations,

still may need to calculate the number of tablets.

• Infusions ( such as IV) calculate drops per minute

• Conversions within the metric system• Rarely need to calculate from apothecary

system.• Drug calculations will be covered in

NR20Lab

Drug Supply & Storage

• Obtained from pharmacy dept.

• Individual Pt. Supply UNIT DOSE

• Stock supply – tylenol, ASA

• Dispensing systems – medication carts, computerized systems, ID bracelet scanning

Drug Abuse by Licensed Professional

• Need to report suspect of abuseGatekeeper role of a professional nurse

• Potential loss of nursing license

• Assistance for licensed professional throughPAP (Professional Assistance Program) NYS Education Department

Bring your LASIX handout with you

To our next lecture on Medication Administration