There are thousands of medications that a nurse can give a patient.

Medications come in many forms and are called by many names. The nurse must make sure that the medication that is to be given is the correct medication for the patient. You will be learning a lot about Pharmacology through the next 3 years! What you learn in Pharm you will use in clinical from here on out what you learn in Nursing will be built upon. You will be held accountable for the knowledge you learn in these foundation classes through the remainder of your nursing career. Potter & Perry Chapter 35 most up to date with regard to regulations ! Be sure and review Pharmacological Concepts, Pharmacokinetics, Type of Medication Action, Medication Dose Responses Pages 687-692 in Potter & Perry. Prescriber: physician, advanced practice nurse (clinical nurse specialist or nurse practitioner), or physicians assistant. -writes the medication order there must be a documented diagnosis, condition, or indication for each medication ordered. -orders may be written or verbal/telephone (thus written by the nurse, then verbalized back to the prescriber) - Verbal orders should be avoided when possible - appropriate use of a verbal order is during an emergency situation it is then transcribed to the MAR and prescribers/physicians order sheet. - If you Have to take a VERBAL ORDER: Box 35-4, p. 700 offers some VERY GOOD Recommendations to reduce error Potter & Perry - Cannot contain abbreviations deemed dangerous following JCAHO's guidelines See table 35-8, pg. 701-703 ORDERS MUST CONTAIN THESE ELEMENTS !!!!! - If you cant read the order what will you do???????? Best practice = CALL MD for clarification!!!! Read Screen: The signature for a verbal or telephone order may be different, as you may be speaking with a nurse or a Nurse practitioner that is screening calls for the prescriber. The nurse is someone who works in the office with the prescriber or the medical group and is given a protocol for medications routine for their patients. Thus the nurse is the person transmitting the order. -Orders can be Standing or Routine; ---- DO NOT Confuse STANDING order with PROTOCOLs (see p. 281). - They are carried out until canceled or another order changes the dose, route, or time.

They can be limited by a certain number of days (narcotics may automatically be d/cd) or a certain number of doses (steroids/antibiotics) or dosages (insulin- may have a sliding scale)

prn, given when the patient requires it - Nurse uses objective and subjective assessments to determine prn administration - the order should have a definitive frequency q1hr, q12h etc. - AND dose give 1 mg for mild pain, 2 mg for severe pain. single or one-time, the medication is only given once ie: as a pre-operative or pre-procedure medication STAT, given immediately for a sudden and critical change in the patients conditions - For cardiac/respiratory arrests stat meds usually kept on crash cart - From pharmacy may have up to 30 min to send up the drug varies with institution NOW orders, - the patient does need the med but it is not necessarily life threatening - A nurse has 90 minutes to administer a now order - Prescription orders are also written on discharge and require the nurse to educate the patient regarding the meds before leaving with the prescription GO TO TRANSPARENCY Physicians Orders - review orders - go over errors on medication order Pharmacists check for the appropriate dosage ---Checks that a proper dosage is prescribed i.e. clarifies if a medication is prescribed for 2000 mg when it should be 200 mg. Pharmacists also - Collaborate with nurses and physicians to evaluate the efficacy of clients medications assists to identify side effects or adverse effects. . - May have a pharmacy tech to assist in the process after which the pharmacist verifies the techs work - NOTE: - Often medications come in prepackaged containers from drug company I have had a few incidences were the outside packaging did not have the same drug name as the inside packaging !!!! IV Piggybacks return to pharm & write up an medication error report!!! Stock supply -rarely used today in hospitals Large multidose containers at Nursing home may have a large bottle of Tylenol Increased risk for errors READ THE LABELS CAREFULLY Unit dose Drawer contains 24 hr dose for each client Each tablet or capsule individually wrapped - may have barcode scanned by the nurse prior to administering medication Prn meds available except controlled substances but

Automated Medicine Dispensing Systems Picture is of a pixas system- Accudose and Omni are other systems Nurse has a Security code to enter system Clients listed, each has own drug profile that can be viewed once the name is activated this info placed into machine by pharmacist/ charge nurse. The dose removed, for that client, and medication counts are Automatically entered into computerized database if a medication is wasted (partial dose, pt. refused, dropped on floor) or The medication is returned this is also documented into the system by the nurse. Nurses role: Utilize the Nursing Process with medication administration assess the procedural & medication orders, - Formulate questions to be considering as you assess the patient Medication Reconciliation - --- See box 35-7 as noted on screen Primary purpose is to be certain that medication the patient has been taking is verified with the current orders. If Discrepancy exists ---- than you are responsible for clarifying the information with their prescriber. - Prescriber may have forgot a BP med pain med - transplant patients must receive anti-rejection medications!!!! - If patient is NPO do some meds need to be changed to another route?? Nurses role: Utilize the Nursing Process with medication administration assess the medication orders, - are the orders complete, drug name, dose, route, time, and patient; assess the patient medical hx, allergies, diet hx, Current conditions: I.E. Pt to receive BP med to treat hypertension what should you check before you give the blood pressure med? Blood Pressure if its low -= hold & call MD. Cultural considerations- may include the clients use of herbal medications which can change the action of a drug, duration or potency. --- some medications are made from pork products which some religious beliefs do not consume Jewish, Muslim must substitute beef products. - Individuals cultural heritage ie race may influence their responses such as metabolism (American Indians - more prone to diabetes and alcoholism r/t inherited physiological make-up. Medications may applicable with nursing diagnosis/analysis ---- If the patients in pain theyll need a pain med, Sometimes the patient will need to have information about a medication. So look over the patients medications and consider the educational needs to be addressed. p 711 of text gives several nursing dx.

Planning use the guidelines for safe medication administration (will go over in a bit) --Wonderful example on page 711 of Potter and Perry, of a Goal statement followed by the Outcome statements. The outcome statements indicate what you want to see happening in the patient that will make the goal possible!! --- Set PRIORITY: work with the client to set goals and outcomes (Tylenol for pain at 3, morphine for pain rated at an 8) ; set priorities and continuity of care Collaborative Care: --- pt to receive pain med 30 min prior to PT. PT to inform nursing of changes in scheduling for physical therapy.
Intervention/Implimentation administer medications following the six rights of medication administration. Be able to explain to pt what the med is and the expected effects of the medication!!! May need to include family in the education especially in acute care. Implementation: Special considerations: Infants/children: size, absorption, med calculation, psychological preparation Older adults: polypharmacy, self-prescribing, OTC, Herbal remedies, misuse of meds (overuse, under use, erratic use, contraindicated use) Noncompliance/nonadherence (deliberate misuse) = 75% of older adults Evaluate & Document the patients response to teaching, and or the medications ( especially BP, Cardiac, diuretic, pain meds) and/or to medication education: I.e. Many policies require that pain levels be evaluated within 2 hours of receiving medication (in practice If IV 30 minutes, If PO within 1 hour). The Pharmacokinetics of a a drug provide the time to onset and will guide youre the time for your evaluation the patients response to that medication Same with a cardiac medication, or pain medication, or sleep medication, or insulin

Transcribe orders accurately Corrected ORDER & MAR Transparencys - Check Orders must be Documented and have : date, drug, dosage, route, time and prescribers signature Those essential elements discussed earlier. - Transcribed orders: may be done by Unit secretary, a nurse, or pharmacist - Check for accuracy - Make sure they match the Original order --- & all medications have been transcribed - MAR Documentation: right date on MAR, right patient, right drug, right dose, right route, right time - Initial and enter codes as needed when drug is given (per policy of facility) Know the medication obtain/review pertinent assessment data ---- Check allergies: should be on each page of the MAR, k the chart/computer, Ask the client BEFORE administering med, if yes ask what type of reaction they had. -- prepare drug cards before coming to clinical. Observe medical asepsis: Which includes? Hand washing before & after handling charts, and before preparing meds.

-minimize handling of med, use barrier (souffl cup/med cup), barrier to set meds on when in the room Observe the 6 rights - we will look at in next screen Calculate the dosage take time to make accurate calculations once a drug is given you can not take it back (especially IV meds) if in doubt have another nurse or pharm double check!!! Work in quiet area for calculations, chart checks not always possible at nurses convenience Check med 3 times before giving- Check the med when taking it out of the drawer 2 when comparing it to the MAR, 3 before removing the wrapper (see handout on blackboad). -- any number of variations but check at least 3 times before it gets to patient Give within 30 min of due time before or after: some facilities have a schedule of blocks of time that medications can be given in and still be considered on time. Report med errors STAT to prescriber Give only meds YOU prepare !!!!! Reality is unless you see it, touch it, mix it, you have no idea what it is so do not give it!!! Document drug, dose, route, time, signature & title. --p. 709. Tell them what medications they are taking If alert and oriented have the right to refuse parents provide permission or refusal for children --- phrase carefully this is your medicine to help you breath better NOT will you take your pills Informed consent for experimental medications, and medications used in some tests Safe administration of course Supportive therapy do they need further education on self-administration, are there other ways of helping them deal with their pain, anxiety, rather than giving them a medication Give medication to help the client and d/c as soon as possible collaborate with prescriber; dont give sleep med for your convenience give if client requests. When giving medications the nurse must make sure that medication errors do not occur. A medication error could cause a patient to have an allergic reaction or cause their illness to become worse. The rights of medication administration is the standard or rules by which the nurse gives medications. 1. The right medication is available. Makes sure medicine package has the same name as On the MAR & check for allergies to the medication (may need new order if allergies present, or a premedication)
nd rd

2. The right dose (the amount of medicine) dose on medication package(s) should match the dose prescribed & is it the correct dose for the patient. Giving more than 4 pills or 4 vials should raise a WARNING to recheck the dose!!! 3. The right patient name should be on the order, MAR, Medication drawer, and Patient (verbal, picture ID, or Name band with identifiers (i.e.: admission# and medication # ) 4. The right route: route is written in order, MAR, and medication package all must match. Can the med be crushed (difficulty swallowing, SR or ER) IS it sustained release, extended release? 5. The right time Time on the MAR and Should agree with the Time Ordered. 6. The right documentation, means that the nurse recorded that all of the above rights on the Medication Administration Record (MAR) were completed.. You should have covered this already in pharmacology, in Potter & Perry text p. 687 - 693 these reviewed again. There are 3 types of names that are given for any one drug. For test purposes I will try to give the generic and brand name Nurse Practice Acts: Dictate who is able or who is not able to administer medications. There are limitations on the types of medications that LPNs may administer, that must be given by a RN. There are some meds such as chemo that can only be given after further education has been received in order to administer. Guidelines for safe Narcotic Administration and control are on page 689, Box 35-1 Documentation for Narcotics includes: the clients name, date, time of medication administration, name of medication dose, signature of nurse dispensing the medication The documentation process is often completed through automated med dispensing machines However, many institutions still use hand written documentation (ie: Nursing Homes). Some institutions Jackson General - also require a full assessment, including BP and HR take place prior to administering narcotics AND After due to the effects of narcotics on the cardiovascular system. Witness by a second nurse is required for any narcotic medication that may be wasted this may be done as pen to paper on the written AMR and/or may be computerized signature. There are many different types of medications . The form given Must be the same as the Form ordered. If ordered as a pill you must get another order to give as liquid, another order for sub- cut, and a different order if given IV.. --- Table 35-2 on page 690 Potter & Perry gives you the different forms of medications KNOW

There are many different forms of liquid medications. Some liquids are given by mouth; Some given only by injections. Different forms of PO meds: Some cant be crushed or drained! Which ones??? SR (sustained release), EL (extended release) be certain that the right medicine is to be given to the patient. be certain that the patient does not have an allergy to the medication that has been ordered. Allergic reactions may cause a patient to itch or it may cause a patient to have an anaphylactic reaction and stop breathing. Allergies that the patient has are written on the medication record. Patients may also have an armband that lets us know that the patient has an allergy. Potter & Perry text p. 687 - 693 The pharmacokinetics involved with medications varies depending on the drug, the form of medication, or site of medication delivery and ability of the drug to be absorbed metabolized and excreted. Before giving the med you will need to know medication Onset & Duration of Action - guides on when to evaluate response. -- ? Medications will have the quickest action when given by what route? IV and inhalation ----------------- but often a shorter duration than p.o. meds. Nurses need to know the therapeutic effect of a medication, Adverse effects (indicate need to stop the med if effects present); Side effects usually minor and will resolve with time. Nurses must also be able to identify an allergic reaction. YOU MAY HAVE AN ALLERGY TO THE MED YOU HANDLE --- What can you do to prevent your own reaction????? The dose of the drug also impacts the effect and patient response to the med. --- i.e. the number of milligrams, the half-life etc. . . . as a nurse YOU will need to know if the medication interacts or is incompatible with any other medications that the patient is receiving look up in drug books, compatibility charts, and collaborate with pharmacist. Assess herbal medication use. Indication/Uses; WHY ARE YOU GIVING this medication? If its for blood pressure check blood pressure before giving bp med Route: PO (whole? Crushed? SR? ER?), IV, SQ Medications can be ordered in many different amounts such as: milligrams (mg), milliliters (mL), micrograms (mcg), or liters (L). A dose given by mouth may be more than the dose that would be given directly into the vein. A drug can not be taken back a medication once it has been given, so the right dose must be given the first time. Some medications may be crushed if the person can not swallow a whole pill, - know if the medication you give can not be crushed

Other medications must be mixed with a liquid in order for the patient to receive the right dose, or for the medication to be able to work best. Some powders are mixed with juice or water so that the patient can swallow it. A primary concern is that the proper dose of medication is administered to the patient. 75% of medication errors are discovered by nurses. The nurse is the LAST stop before the medication reaches the patient you are ultimately responsible for what happens next!!! especially if there is an error in the prescribing/administering process that could be fatal. 3 types of measurement: metric, apothecary, household - Metric most commonly used by healthcare professionals Mrs. Patterson covering in Med-Calc. = will only touch on calculations here JCAHO (Joint Commission on Accreditation of Healthcare Organizations established that trailing zeros cannot be used after January 1, 2004. Other abbreviations that have been discontinued are listed on table - P. 701 -703 Pay special attention to the items with single and double stars. --- Old habits are hard to break so you may see orders written using these terms even though nearly all the doctors notes have a table that informs the MD of the proper notation to be used!!! Household measurements are familiar to clients Drops, teaspoons, tablespoons, and cups (volume) Pints, quarts (weight) Disadvantage = inaccurate === tsp and cups vary in size Advantage = familiarity and convenience Table 35-7, page 696 Potter & Perry gives equivalents of household, apothecary & metric units. This conversion table must simply be memorized in order to be sure that the right dose is given when converting from one system of measurement to another. For instance the physician may order that Robitussin 30 ml be taken by the patient every 6 hours. Many medication containers use the metric system but some do not. Some patients would rather use a spoon than the handy little cups. 30 ml of Robitussin would be equivalent to how many tbsp? 2 tbsp How many ounces? to how many tsp? 1 ounce 6 tsp

Error prevention: Do not confuse equivalents!!! When in a hurry, it may be easy to misread equivalents (e.g., milligram instead of milliliter).

this table similar to 35-7 in Potter & Perry, on page 696. For instance the physician may order that Robitussin 30 ml be taken by the patient every 6 hours. Many medication containers use the metric system but some do not. Some patients would rather use a spoon than the handy little cups. 30 ml of Robitussin would be equivalent to how many tbsp? 2 tbsp How many ounces? to how many tsp? 1 ounce 6 tsp

Error prevention: Do not confuse equivalents!!! When in a hurry, it may be easy to misread equivalents (e.g., milligram instead of milliliter). Example one: The FNP orders that 2 mg of a liquid medication be given. = the dose ordered But the dose you have on hand is 10 mg of the medication = the dose on hand ---- so you only want 2 mg out of the 10 mg/ available That 10 mg is in 20 ml of solution = the amount on hand 2 mg X 20 ml = .2 X 20 = 4 ml 10 mg Now calculate the amount to administer 2 divided by 10 is 0.2 0.2 times 20 = 4ml The same problem is worked out as a ratio in example 2. Example 3 would apply to a pill form HOW MANY TABS WOULD YOU GIVE? you would give tab If you calculate that more than 4 tablets of one medication are to be given this should give you reason to question the math & to question the order. Medications can be ordered for many different times. Some medications are given at a specific time of the day such as in the morning or at bedtime h.s., a.c. = before meals, p.c. after meals. Some medications can not be given with any other medication or with food. So the med is given several hours before or after other medications or meals. REVIEW: STAT? = Medications that are ordered STAT must be given immediately. NOW? as soon as possible- but not emergent, PRN ? medications are given only when the patient asks for them. For example the nurse would only give a medicine for pain when the patient is having pain. Routine ? medications are given at specific times.

Most medications are ordered to be given at specific times such as every 4, 8, or 12 hours. Best to give routine or scheduled medication within 30 min to 1 hour of time due (each facility is different).

make sure the medication is getting to the right client (patient) so that the patient does not get the wrong medication. Getting the right medicine to the right patient may be difficult for many reasons: 1. the nurse may give medicines to many patients; 2. some patients may have similar names (John Smith, and John J. Smith are 2 different people); 3. patients may not be able to tell you their names because they can not speak, cannot remember their full name, or they are not awake and alert enough to tell the nurse their name. By making sure that the same name is on the medication order and record, the medicine container, and the patients bracelet, the nurse can be certain that the right client is going to get the medication. Went over the Orders and MAR earlier but as a reminder The medication administration record is the Right document to note the Right medication was given at the Right dose, to the Right client, by the Right route, at the Right time. If the nurse does not document that the medication was given- then the assumption is that it was NOT done , AND another nurse may try to give the medication. This could cause the patient to have to stay in the hospital much longer- even death. In a few minutes take a break - & when you come back pull out your copy of the MD orders and MAR and practice the process for pulling meds.