Nursing responsibilities for safe administration
Responsibilities:
1. 6 Rights: Right pt, drug, dose, time, route, and documentation; and nursing judgment
- Medication knowledge/sources of information
- Medication standards
- Pt-related variables
- Clarifying orders
Adverse drug events
Adverse events:
1. Inaccurate recording and transcribing orders
- Unclear or erroneous labeling, or expiration of drugs
- Pt misidentification
- Incomplete delivery of drugs
- Verification errors
- Use of inadequate knowledge or inaccurate knowledge base
- Time and performance pressure
New safety measures
Safety instutions:
1. Institute of Medicine (IOM); refer to IOM-QSEN to avoid medication errors
- JCAHO National Pt Safety Goals
- Electronic health record (EHR)
- Newly designed delivery systems
Unit-dose drug distribution system
Pre-packaged, pre-labeled, individualized doses
SAFEST, most efficient, and most economical
Systems of medication safety
Safety systems:
1. Automated medication dispensing systems (i.e. Pyxis)
- Fingerprint/password
- Controlled substances
- Barcode medication administration: Pt barcode is scanned and compared to medication to ensure 6 rights
Drugs and medications
Types of medications:
1. NON-PRESCRIPTION meds. – OTC; FDA-approved and controlled (i.e. Tylenol)
- PRESCRIPTION meds. – Require supervision to safely determine therapeutic vs. toxic effects
- HERBS & BOTANICALS – Determine safety, potency, and drug interactions
Medication order
Components:
1. DRUG NAME – Brand/trade or generic name; Capitalized lettering helps differentiate meds. that look/sound alike
- DOSE & TIME – Strength and frequency
- ROUTE – PO, IM, IV, ID, SC, sublingual, otic, ophthalmic, and transdermal
- PURPOSE – i.e. Pain, fever, N/; medication order must address specific purpose
- SIGNATURE
Types of medication orders
Medication orders:
1. Electronic (EPIC)
- PRN order – requires assessment and nursing judgment
- Routine order – detailed order for a medication given on a routine or regularly scheduled basis (i.e. Insulin)
- Standing protocol – pre-written medication orders and specific instructions to administer a medication to a person in clearly defined circumstances (i.e. Hypoglycemic treatment algorithm protocol)
- Single/one-time order – i.e. Pre-op, emergency-related orders
- Tritation order – the medication dose is either progressively increased or decreased in response to the patient’s status (i.e. Heparin adjustment using PTT)
- Verbal order (rare)
Patient controlled analgesics (PCA)
Method of allowing a person in pain to administer analgesics (i.e. Morphine sulfate, Dilaudid)
Child PCA usually with Narcan drip (narcotic antidote) – Helps reduce side effects, itching, and N/
PCA rates:
1. BASAL: Continuous infusion for pain control
- BOLUS: Pt self-medicated dose as needed; locks to prevent overdose
Principles of drug action
Principles:
PHARMACOKINETICS: What the body does to the drug – i.e. Absorption, distribution, metabolism, and excretion
PHARMACODYNAMICS: What the drug does to the body – i.e. Therapeutic effects, adverse effects, side effects, tolerance, allergic reactions, and toxicity
Medication assessment
Assess:
1. PMHX
- Allergies (and reactions), and intolerances
- Medication history (Past, present, and alleviating meds.)
- Medication record/orders
- Diet and fluid orders
- Laboratory values
Physical assessment
Assess:
1. Ability to swallow – especially infants/children, elderly, and pts with GERD
- GI motility – i.e. PO route is contraindicative if V/D/
- Adequate muscle mass
- Patent venous access
- Vital signs
- Body system assessment (Right response)
- Assessment of knowledge and compliance
Safe medication administration
Nursing safety measures:
1. Interpret order
- Calculate adult/child dosage
- Inform the pt what they are receiving
- Assess pt understanding of medication
- Assess pt allergies and history
- Administer meds. according to 6 rights
Preventing medication errors
Prevent medication error by:
1. Redesigning delivery systems – i.e. POE (provider order entry), infusion pumps
- Creating safety cultures – QI (quality improvement) to instill a culture of pt safety (i.e. reporting errors)
- Maximizing interprofessional communication
- Barcode scanning
- Simulation
- Classifying high risk meds. – i.e. Narcotics, insulin, heparin, potassium which increase risk to cause harm
- Identifying at-risk populations – Pediatric and elderly populations (due to to varying size and weight)
**Critical thinking, and personal judgment, knowledge, and responsibility
Special circumstances
Some medications require: Special handling, refrigeration, or to be prepared a certain way
Children/Elderly:
1. Parent may help administer
- Child should help if possible
- Dilute in small amounts of something the child likes
- Offer assistance to elderly pt
- Use liquids, crush pills, and allow time
Medication routes
Routes:
1. ORAL – Minimizes discomfort, fewest side effects, and inexpensive; Unit-dose pills/tablets can be scored or crushed (do NOT crush enteric-coated or sustained-release tablets)
- SUBLINGUAL: Placed under the tongue (i.e. Nitroglycerine for chest pain)
- BUCCAL – i.e. Nystatin for fungal infections
- TOPICAL: Penetrates the epidermis (i.e. Preparation H, cortisone)
- TRANSDERMAL: Penetrates the epidermis and dermis, and enters the blood circulation (i.e. Hormones, BP meds.)
- OPHTHALMIC, OTIC, NASAL – Eyes, ears, nose (i.e. Visine, Flonase)
- RECTAL/VAGINAL – Lubricate prior to insertion (i.e. Glycerin, Tylenol suppository)
- INHALED: Aerosolized medication that is absorbed by the respiratory tract (i.e. Albuterol via nebulizer or MDI spacer)
- PARENTERAL – IM, SC, IV, and ID
SC injections
Purpose: Slow, sustained release of medication; Small amount of solution = 0.5-1ml
Medications – i.e. Insulin, LMWH, vaccines (MMR), some narcotics, and pre-op meds.
Needle and syringe:
SIZE: 25-30 G (5/8’‘-0.5’’)
ANGLE: 90 degrees (adult) and 45 degrees (infant/child or emaciated adult)
Sites for injection:
- Abdomen
- Lateral aspects of upper arms
- Anterior mid thighs
- Buttocks
- Lower back
- Hips
- Scapula
Insulin
Hormone made by the pancreas that regulates BG
Administered SC and calibrated via an insulin syringe in UNITS (orange cap)
100 units = 1 cc; **Note: 100-unit syringes are in 2 unit increments, and 50-unit syringes in 1 unit increments
Sites are rotated within an anatomical area, approx. 4-6 injections per site
Insulin preparations
Types of insulin:
1. REGULAR (Short-acting): Onset: 30-60 min., peak: 2-3 hrs., duration: 3-6 hrs.; Clear
- NPH (Intermediate-acting): Onset: 2-4 hrs., peak: 4-10 hrs., duration: 10-16 hrs.; Cloudy
- COMBINATION (Short/intermediate-acting)
- ASPART, Novolog & LISPRO, Humolog (Rapid-acting): Onset: <15 min., peak: 1-2 hrs., duration: 3-4 hrs.
- GLARGINE, Lantus (Long-acting): Onset: 2-4 hrs., NO peak, duration: 20-24 hrs.
S/S of Hypo/Hyperglycemia
HYPOGLYCEMIA – S/S: Faintness/dizziness, rapid heartbeat, hunger, nervousness/tremor, changes in vision, unsteady gait/slurred speech, BG <70 mg/dl, seizures/coma
HYPERGLYCEMIA – S/S: Weakness/fatigue, increased urination, glycosuria, abdominal cramps, N/V/, HA, blurred vision, elevated BG
Mixing insulin
Draw up regular insulin (short-acting) first, then NPH (intermediate)
Heparin
An anticoagulant/antiembolitic that inhibits the activity of several blood clotting factors
Types of heparin:
1. UNFRACTIONATED: Usually given IV for PE d/t VT (can also be given SC); Requires frequent PTT monitoring; Usual dose for clot treatment/prevention – 50,000 units/L IV fluid or 5,000 units SC
- LMWH (i.e. Lovenox): More predictable pharmokinetics and anticoagulation effects (product of choice); Does NOT require frequent PTT monitoring; Ideal: Different concentrations, pre-measured (with air bubble in syringe), easy to use (but costly), and fewer complications
**Draw up 0.1-0.2ml of air for SC injections = Prevents leakage of heparin into ID layers (bruising)
IM injections
Purpose: Used for irritating medications and quicker onset; less likely to cause tissue necrosis (d/t increased vascularization); Larger amount of solution than SC
Medications – i.e. Tetanus, PCN, and B12
Needle and syringe:
SIZE: Adult – 20-23 G (1.5’‘-1’’); Infant/child – 22-27 G (1’‘-0.5’’)
ANGLE: 90 degrees
Sites:
1. VENTROGLUTEAL – Preferred site for adults; safest, least painful, and free of major BVs, nerves, and fat
- VASTUS LATERALIS – Preferred site for infants/children (0.5-2ml)
- DELTOID – NOT recommended for children <18 mos. (0.5-1ml); Small muscle within close proximity to radial nerve and brachial artery; Non-irritating, low viscosity solutions (i.e. Vaccines, narcotics)
- RECTUS FEMORIS
- DORSOGLUTEAL – NOT recommended; Close proximity to sciatic nerve and superior gluteal artery
**Inject slowly and massage site after injection
Z-track technique for IM injections
Purpose: Thick and irritating medications injected into large muscles (i.e. Ventrogluteal or vastus laterals); do NOT perform technique in deltoid
Technique steps:
1. Add 0.1-0.2ml air bubble
- Pull/retract SC tissue before inserting IM at 90 degrees
- Inject medication slowly and withdraw needle
- Allow SC tissue to move back in place
to seal medication in site - Do NOT massage
