MEDICATION ADMINISTRATION: Oral

 

Medication Administration: Oral

 

Preparation and Route

         Drugs are available in many forms for administration by a specific route (see Drug Preparations). The route refers to how the drug is absorbed: oral, buccal, sublingual, rectal, parenteral (hypodermic routes), topical, and inhalation. Drugs prepared for administration by one route should not be substituted by other drug forms. For example, when a client has difficulty swallowing a large tablet or capsule, the nurse should not administer an oral solution or elixir of the same drug without first consulting the physician because a liquid may be more easily and completely absorbed, producing a higher blood level than a tablet. The nurse should be aware of the various drug forms and how they are administered. Certain drug preparations require special consideration regarding administration.

For example:

• Chewable tablets are designed to be chewed before swallowing because chewing enhances gastric absorption.

• Buccal and sublingual medications must be allowed to dissolve completely before the client can drink or eat.

• Suspensions and emulsions should be administered immediately after shaking and pouring from the bottle.

Oral Route

         Most drugs are administered by the oral route because it is the safest, most convenient, and least expensive method. The disadvantage of the oral route is that it is slower acting than the other routes, such as injectables. Drugs may not be given orally to clients with gastrointestinal intolerance or those on NPO (nothing by mouth) status. Oral drugs should be given with caution to clients who have difficulty swallowing, such as a patient who has had a cerebrovascular accident (stroke). Oral administration is also precluded by unconsciousness. When small amounts of drugs are required, the buccal (cheek) or sublingual route is used. Drugs administered through these routes act quickly because of the oral mucosa’s thin epithelium and large vascular system, which allows the drug to quickly be absorbed by the blood. Certain oral drugs are prepared for sublingual or buccal administration to prevent their destruction or transformation in the stomach or small intestines. Buccal drugs are designed to be placed in the buccal pocket (superiorposterior aspect of the internal cheek next to the molars) for absorption by the mucous membrane of the mouth. Sublingual medications are designed to dissolve quickly when placed under the tongue. For example erythrityl tetranitrate (an anti-anginal) can be given either sublingually or buccally as prescribed, whereas isoproterenol hydrochloride (a bronchodilator) and nitroglycerin (an anti-anginal) are given sublingually, and methyltesterone (an androgen) is given only buccally.

 

 

 

 

Drug Information Worksheet

 

 

 

Frequent Medications with Values & Vital Signs

Prepared by E. Ross, RN, BSN

1.    Betablockers– Pulse(hold <50) “Beta B 50”, Blood pressure (hold if BP <100)

2.    Calcium Channel Blockers– BP

3.    Potassium – K⁺ level

4.    Lovenox/Heparin– Subcutaneous-hold for platelets less than 100,000

5.    Ace Inhibitor– BP (pril)

6.    Heparin IV– PTT

7.    Angiotension Inhibitors – BP

8.    Coumadin– PT and INR

9.    Nitrates– BP

10.                       Lanoxin/Digoxin– Apical pulse (hold<60) Dig level (hold is >2.0)

11.                       Any drugs that cause toxicity– for example Dilantin, Theophyllilne, digoxin, Phenobarbital, Tegretal.  Clue:  Drugs that mention in drug book toxicity/overdose may have levels ordered.

12.                       Thiazide like diuretics and Loop of Henle diuretics– lower K⁺ – Check levels and BP

13.                       Potassium sparing diuretics– keep K⁺-check levels and BP

Hold any BP medication for systolic BP<100.  Check for physician ordered parameters.  The physiciaeeds to be notified when the drug is held unless there are ordered parameters.

 

Drug Interaction

 

         Drug interaction refers to the effect one drug can have on another. Drug interactions may occur when one drug is administered in combination with a second drug or when a short time interval exists between the administration of two different drugs. Drugs can be combined deliberately to produce a positive effect, as when hydrochlorothiazide (a potassium-depleting diuretic) is combined with spironolactone (a potassium-sparing diuretic) to maintain a normal blood level of potassium. A positive drug combination can also occur when one drug, such as a preoperative medication, is deliberately given to potentiate the action of another drug. Not all drug combinations are therapeutic. Some drug combinations can interfere with the absorption, effect, or excretion of other drugs. For example, calcium products and magnesium-containing antacids can cause inadequate absorption of tetracycline (antibiotic) in the digestive tract.

 

Side Effects

and Adverse Reactions

 

         Drug effects other than those that are therapeutically intended and expected are called adverse reactions. A nontherapeutic effect may be mild and predictable (side effect) or unexpected and potentially hazardous (adverse effect). There are several types of adverse reactions: drug allergy, drug tolerance, toxic effect, and idiosyncratic reactions.

         Drug allergy (hypersensitivity) is an antigen-antibody immune reaction that occurs when an individual who has been previously exposed to a drug has developed antibodies against the drug. The type of reaction may be mild (skin rash, urticaria, headache, nausea, or vomiting) or severe (anaphylaxis). Drug reactions are often manifested in the skin because of its abundant blood supply. Anaphylaxis is an immediate, life-threatening reaction to a drug, such as penicillin, characterized by respiratory distress, sudden severe bronchospasm, and cardiovascular collapse. If emergency measures (administration of

epinephrine, bronchodilators, and antihistamines) are not instituted immediately, anaphylaxis can be fatal.

         Drug tolerance occurs when the body becomes so   accustomed to a specific drug that larger doses are needed to produce the desired therapeutic effect. For example, cancer clients with severe pain may require larger and larger doses of morphine (narcotic analgesic) to control the pain as the body builds up a tolerance to the morphine.

 

         A toxic effect occurs when the body cannot metabolize a drug, causing the drug to accumulate in the blood. Toxic reactions can result after prolonged intake of high doses of medication or after only one dose. An idiosyncratic reaction is a highly unpredictable response that may be manifested by overresponse, underresponse, or an atypical response. For example, 1 of 40,000 clients will develop aplastic anemia after receiving chloramphenicol (antibiotic) (Springhouse, 1997).

 

Food and Drug Interactions

 

         Medication management requires avoidance of possible food and drug interactions. There are three primary types of food and drug interaction:

 

1. Certain drugs may interfere with the absorption, excretion, or use in the body of one or more nutrients.

2. Certain foods may increase or decrease the absorption of a drug into the body.

3. Certain foods may alter the chemical actions of drugs, preventing their therapeutic effect on the body.

FACTORS INFLUENCING

DRUG ACTION

 

         Individual client characteristics such as genetic factors, age, height and weight, and physical and mental conditions can influence the action of drugs on the body. Sometimes mistaken for drug allergies, genetic factors can interfere with drug  metabolism and produce an abnormal sensitivity to certain drugs. The nurse should consider age-related factors that can influence drug action and dosing. For example, neonates and infants have underdeveloped gastrointestinal systems, muscle mass, and metabolic enzyme systems and inadequate renal function; elderly clients often experience decreased hepatic or renal function and diminished muscle mass. The physician often correlates the client’s age, height, and weight when determining the dosage for many drugs. The nurse should make sure that this information is accurately recorded in the client’s medical record. The amount of body fat may also alter drug distribution because some drugs such as digoxin (inotropic) are poorly distributed to fatty tissues. The client’s physical condition can also alter the effects of drugs. For example, in an edematous client the drug must be distributed to a larger volume of body fluids than for a nonedematous client; therefore, the edematous client may require a larger drug dose to produce the drug action, whereas a dehydrated client would require a smaller dosage. Diseases that affect liver and renal functions can alter the metabolism and elimination

of most drugs.

 

PROFESSIONAL ROLES

IN MEDICATION

ADMINISTRATION

 

         The health care practitioner determines the therapeutic drug plan and conveys the plan to others by initiating orders or a prescription. In health care settings (longterm care facilities and hospitals), medication orders are written on a health care practitioner’s order form. Health care practicioners can also write medication orders on legal prescription pads or through the computer terminal. When allowed by organizational policy, the health care practitioner may also give medication orders via telephone or as a verbal order. If the health care practitioner gives a medication order orally, either directly or over the telephone, the nurse enters the information on the medical record. This information includes the name of the health care practitioner who ordered the medication, the name of the medication, the dosage, the frequency, the route of administration, and the nurse’s name. Most institutions require the health care practitioner to confirm oral orders within 24 hours; the nurse is responsible for ensuring that the verbal order is clear. It often helps for the nurse to repeat the order to the health care practitioner to make sure it was interpreted as intended. See Chapter 26 for a complete discussion of written and verbal orders and the role of the nurse in transcribing orders. The pharmacist processes the health care practitioner’s orders, clarifies any entries that are unclear, and prepares the medications for adminsitration. The pharmacist is responsbile for filling prescriptions and for making sure they are valid entries. Pharmacists also assess medication plans monitoring for incompatabilities and, at times, recommending the best time to admistister a medication to obtain therapeutic benefit such as Lovastatin (cholesterol lowering drug) which is most effective if taken in the evening. The pharmacist participates in calculating the appropriate dosage of certain medications such as anti-infective drugs (e.g., gentamycine). These dosages are based on the patient’s body weight and kidney function and may be adjusted during the course of therapy by the pharmacist with the health care practitioner’s consent. Nurses frequently consult with pharmacists in determining compatibility if intravenous medications are to be administered simulatneously. Pharmacists also answer medication-related questions for both nurses and patients. Nurses spend a great deal of time with their patients and have specific knowledge and skills that qualify them to administer medication and to evaluate a medication’s effectiveness. Nurses understand why particular medications are ordered for clients and what physiological changes may result from the medication that cause a therapeutic effect. Because of their knowledge, skills, and frequent client contact, nurses can readily assess changes in a client’s condition and can determine whether it is appropriate to administer a medication on the basis of the client’s condition. Nurses are responsible for teaching patients to selfadminister medications such as insulin and for assessing the patient’s ability to self-administer correctly. Before discharge, nurses teach clients about the medications they will be taking at home and how to assess for side effects and adverse reactions. Using the nursing process, nurses help clients incorporate their medication regimen into their plan of care. When a client is admitted to an inpatient health care facility, the drug order form is stamped with the client’s name, room number, age, and weight. The client’s weight is used by the pharmacist in compounding and dispensing drugs. Most agencies have policies relative to medication administration, such as stop dates for certain types of drugs, regularly scheduled times to administer medications as specified in the drug order, and a listing of

abbreviations officially accepted for use in the agency. The agency’s medical records department maintains the official listing of abbreviations adopted by the medical staff; only abbreviations from the official list can be used in any part of the client’s medical record. See the accompanying display for a list of common abbreviations used in medication orders.

Types of Medication Orders

 

         The health care practitioner prescribes medications in different ways, depending on their purpose. Medications can be prescribed as stat, single-dose, standing, and prn orders.

 

Stat Orders

 

         When the health care practitioner writes orders, the nurse should read all of the orders to determine if any stat orders have been prescribed. A stat order is an order for a single dose of medication to be given immediately. Stat drugs are often prescribed in emergency situations to modify a serious physiological response; a stat dose of nitroglycerin may be ordered for a client experiencing chest pain. The nurse should assess and document the client’s response to all stat medications.

 

Single-dose Orders

        

         Single-dose orders are one-time medications or may require the administration of drops or tablets over a short period of  time. The nurse should administer single-dose orders only once, either at a time specified by the health care practitioner or at the earliest convenient time. These drugs are often prescribed in preparation for a diagnostic or therapeutic procedure; for example, radiopaque tablets may be administered in preparation for a gallbladder test, or a one-time order may be given for a preoperative medication.

 

Standing Orders

 

         Standing orders are also referred to as scheduled orders because they are administered routinely as specified until the order is canceled by another order. The standing orders stay in effect until the health care practitioner discontinues or modifies the dosage or frequency with another order or until a prescribed number of days has elapsed as determined by agency policy. The purpose of a standing medication order is to maintain the desired blood level of the medication. Agency policy determines the actual times for administering medications for a 24-hour time interval. For example, t.i.d. drugs may be administered at 0800, 1400, and 2000 or at 0900, 1500, and 2100. Medications ordered qd may have a specified time identified in the order, such as Isophane (NPH) Insulin 10 U SC qd at 0600, or they may be given at the agency’s designated time, for example, Lanoxin 0.25 mg PO qd 0900. When the order specifies the number of days or the number of dosages of the drug the client is to receive, the order has an automatic stop date to discontinue the drug. For example, the order may read tetracycline 250 mg PO q6h for 5 days. The nurse should execute this order by administering 250 mg tetracycline orally every 6 hours for 5 days for a total of 20 doses. Day one begins with the administration of the drug and the time the first dose is given. If the first dose of tetracycline is given on a Tuesday at 1200, then every 6 hours, the last dose will be given on Sunday at 0600. Although the medication is given over 6 consecutive days, it totals 20 doses as ordered. Most agencies have an automatic stop date to discontinue certain medications, such as 5 or 7 days for antibiotics and 48 or 72 hours for narcotics.

 

prn Orders

 

         A drug may be ordered on a prn (as needed) basis as circumstances indicate. The drug is administered when, in the nurse’s judgment, the client’s condition requires it. Before administering a prn medication, the nurse must thoroughly assess the client, using both objective and subjective data in determining the appropriateness of administering the medication. This

type of order is commonly written for analgesics, antiemetics, and laxatives. The order written by the health care practitioner indicates how frequently a prn medication can be given. A nurse cannot administer a prn medication more frequently than the order indicates without consulting with the health care practitioner for a change in that order. Examples of prn orders are meperidine (a narcotic analgesic) 75 mg IM q3–4 hours prn incisional pain and Tylenol 650 mg q4 hours prn headache. When the prn medication has been administered, the nurse documents the assessment and the time of administration. In addition, the nurse is responsible for monitoring the effectiveness of the medication and documenting the effect in the client’s medical record. The nurse administers the pain medication on the basis of the assessment of the client’s

pain and as specified in the order.

 

NURS I N G   T I P

Therapeutic Levels

         Some medications require monitoring of blood levels to determine their effectiveness. When reviewing these laboratory values, notice if the levels are higher (toxic) or lower (subtherapeutic) than the recommended therapeutic range for that medication. Adjustments in the medication dose by the health care practitioner may be warranted to reach the recommended therapeutic level.

 

Parts of the Drug Order

 

All orders should be written clearly and legibly, and the drug order should contain seven parts:

1. The name of the client

2. The date and time when the order is written

3. The name of the drug to be administered

4. The dosage

5. The route by which it is to be administered and special directives about its administration

6. The time of administration and frequency

7. The signature of the person writing the order, such as the physician or advanced practice registered nurse Drug prescriptions written in settings other than acute care facilities may also specify whether the generic or trade name of the drug is to be dispensed, the quantity to be dispensed, and how many times the prescription can be refilled.

 

SYSTEMS OF

WEIGHT AND MEASURE

 

 

Medication administration requires the nurse to have a knowledge of weight and volume measurement systems. In North America there are three systems of measurement used in medication management: metric, apothecary, and household.

 

Metric System

 

         The metric system of weights and measures was adopted by the USP in 1890 and the British Pharmacopoeia in 1914 to the exclusion of all other systems except for equivalent dosages. The Council on Pharmacy and Chemistry of the American Medical Association adopted the metric system exclusively in 1944. Resistance to changing established customs interfered with the exclusive adoption of the metric system. Today, the metric system is used in every major country of the world and is used almost exclusively in the U.S. medical practice (Remington’s Pharmaceutical Sciences, 1990). The metric, or decimal, system is a simple system of measurement based on units of 10. The basic units can be multiplied or divided by 10 to form secondary units. The decimal point is moved to the right for calculating multiples, and the decimal point is moved to the left for division. The basic units of measurement in the metric system are the meter (linear), the liter (volume), and the gram (mass). The metric system uses prefixes derived from Latin to designate subdivisions of the basic units and prefixes derived from Greek to designate multiples of the basic units (see the accompanying display). When the metric system is used, a zero is always placed in front of the decimal for values less than 1 (e.g., 0.5) to prevent error.

 

 

 

 

 

Apothecary System

 

 

         The apothecary system, which originated in England, is based on the weight of one grain of wheat. Therefore, the basic unit of weight is the grain (gr), and the basic unit of volume is the minim (the approximate volume of water that  eighs a grain). The grain is expressed in fractions such as morphine gr 1/4. The minim (m) is the smallest unit of volume, followed in ascending order by the fluid dram (D), fluid ounce (Z), pint (pt), quart (qt), and gallon (gal).

 

Household System

 

         The household system of measurement is similar to the apothecary system of liquid measures and is the least accurate of the three systems. The units of liquid measure are drop (gtt), teaspoon (tsp), tablespoon (Tbsp), cup, and glass. Household units are often used to inform clients of the size of a liquid dose. The USP recognizes the use of the teaspoon as the ordinary practice for household medication administration and states that the teaspoon may be regarded as representing 5 ml (American Hospital Formulary Service, 1996). Household spoons are not appropriate when accurate measurement of a liquid dose is required; therefore, the USP recommends that a calibrated oral syringe or dropper be used for accurate measurement of liquid drug doses.

 

APPROXIMATE DOSE

EQUIVALENTS

 

         The conversion of metric doses with the apothecary and household systems are approximate dose equivalents (see the accompanying display). The approximate dose equivalents represent the quantities usually ordered by health care   practitioners when using either the metric or apothecary system of weights and volumes for drug doses (American Hospital Formulary Service, 1996). If the prepared dosage form is prescribed in the metric system, the pharmacist may dispense the corresponding approxi mate equivalent in the apothecary system and vice versa. For example, if the health care practitioner prescribes morphine gr 1/4, the pharmacist may dispense morphine 15 mg. The USP and NF reference exact equivalents that must be used to calculate quantities in pharmaceutical formularies and prescription compounding.

 

METRIC SYSTEM PREFIXES

 

Latin Prefixes—Subdivisions of the Basic Unit

deci (1/10, or 0.1)

centi (1/100, or 0.01)

milli (1/1000, or 0.001)

 

Greek Prefixes—Multiples of the Basic Unit

deka (10)

hecto (100)

kilo (1000)

 

Converting Units

of Weight and Volume

 

         The nurse has to apply the knowledge of measurement systems and their conversions when the health care practitioner prescribes a drug dosage in one system and the pharmacy dispenses the equivalent dose in another. Given the above example of morphine, if the health care practitioner orders morphine gr 1/4 and the pharmacist dispenses morphine 15 mg, the nurse is responsible for ensuring the correct dose. The nurse knows that 1 grain equals 60 milligrams; to convert the ordered dose to milligrams, the nurse should use the following calculation:

 

1 gr = 60 mg

x = 1/4 gr × 60 mg/gr

(the grains cancel out)

x = 60/4 mg

x = 15 mg

 

 

Measurement Conversions

within the Metric System

 

Because the metric system is based on units of 10, dose equivalents within the system are computed by simple arithmetic, either dividing or multiplying. For example, to change milligrams to grams (1,000 mg equals 1 g) or milliliters to liters (1,000 ml equals 1 L), divide the number by 1000:

250 mg = x g

(move the decimal point three places to the left)

x = 0.25 g

or

500 ml = x L

(move the decimal point three places to the left)

x = 0.5 L

To convert grams to milligrams or liters to milliliters, the nurse multiplies the number by 1000:

0.005 g = x mg

(move the decimal point three places to the right)

x = 5 mg

or

0.725 L = x ml

(move the decimal point three places to the right) x = 725 ml The nurse may need to convert the volumes of liters and milliliters for enemas and irrigating solutions such as for bladder and wound irrigations. Intravenous solutions are sterile, prepackaged solutions dispensed in volumes as ordered by the health care practitioner, such as 50 ml, 100 ml, 250 ml, 500 ml, and 1,000 ml (1 liter).

 

 

 

 

 

Measurement Conversions

between Systems

 

         When converting grains to milligrams, the nurse must multiply by 60. For example, if the physician orders nitroglycerin (anti-anginal) 1/150 gr PO for chest pain, the dispensed dose will be 0.4 mg:

1 gr = 60 mg

x = 1/150 gr × 60 mg/gr

(the grains cancel out)

x = 1/150 × 60/ 1 mg

x = 60/150 mg

(divide 60 by 150)

x = 0.4 mg

The nurse converts between pounds and kilograms (2.2 lb = 1 kg) by dividing or multiplying by 2.2. For example, if the ordered dose is 10 mg/kg and the client weighs 150 lb:

150 lb 10 mg/kg

2.2lb/kg x

(the lb and kg cancel out)

x = 68.2 × 10 mg

 x = 682 mg

In clinical settings, household measures are used for bedside recording of intake so that the client or family member can record the volume ingested by the client. Agencies have a legend on their intake form with the approximate conversions from household to metric volume measures based on the type of containers used in that specific agency. See Chapter 37 for the procedure for measuring intake and output. Home health nurses often have to convert a liquid dose to an approximate

household unit.

 

 

 

 

 

Drug Dose Calculations

 

         Several formulas may be used by the nurse when calculating drug doses. One formula uses ratios based on the

dose on hand and the dose desired. For example, cephalexin (anti-infective cephalosporin) 500 mg PO q.i.d. (dose desired) is ordered by the health care practitioner; the dose on hand is 250 mg/5 ml. The formula is as follows:

250 mg (dose on hand) 500 mg (dose desired)

5 ml (dose on hand) x (dose desired)

(cross-multiply)

250 x = 5 × 500

5 × 500

250

x = 10 ml

         The ratio formula can be used in calculating dosages. For example, the health care practitioner orders heparin  (anticoagulant) 10,000 units SC; the dose on hand is 40,000 units/ml:

40,000 units 10,000 units

1 ml x

(units cancel out)

40,000 x = 10,000

x =

x = 1/4

x = 0.25 ml

 

Pediatric Dosages

 

“Children are sometimes more susceptible than adults to certain drugs” (Remington’s Pharmaceutical Sciences, 1990, p. 91). Several rules have been devised to calculate infants’ and childrens’ dosages such as Young’s Rule, Clark’s Rule, and Fried’s Rule, but these rules give only approximate dosages. Even when pediatric drug dosages are calculated on body surface area, weight, and age of the child, they are based on a proportion of the usual adult dose (approximate). Regardless of the method used in calculating pediatric drug dosages, the nurse should realize that dosages are approximate and ofteeed adjustment based on the child’s response. The body surface area method of determining pediatric doses is based on the body surface area of an adult weighing 150 lb. The body surface area of an adult weighing 150 lb. is 1.73 square meters. The approximate child dose is calculated as follows: Body surface area of child Body surface area of adult = approximate child dose Body suface area of child (m2) × adult dose 1.73 m2 = approximate child dose Nomograms based on height and weight are used to compute the body surface area (Figure 29-2). A straight line is drawn from the client’s height in the left column to the client’s weight in the right column. The point at which this line intersects the body surface area column (designated SA) indicates the body surface area. Nomograms are used primarily in calculating pediatric drug dosages; however, they are also used when calculating some adult drug dosages such as aminoglycosides and antineoplastic agents.

 

 

SAFE DRUG

ADMINISTRATION

 

Nurses must administer numerous drugs daily in a safe and efficient manner. The nurse should administer drugs in accord with nursing standards of practice and agency policy. The safe storage and maintenance of an adequate supply of drugs are other responsibilities of the nurse. The nurse documents the actual administration of medications on the medication administration record, or MAR. The MAR is a medical record form that contains the drug’s name, dose, route, and frequency of administration. Drug data are entered either by the nurse when transcribing the order (handwritten onto the form) or by the pharmacist when dispensing the order (a computer-generated pharmacy MAR form is shown in Figure 29-3).

 

 

 

Figure 29-2 Nomogram for Estimating Body Surface Area.

Reprinted with permission from Behrman, R.E., Kliegman, R., &

Arvin, A. M. (Eds.). (1996). Nelson textbook of pediatrics (15th ed.).

Philadelphia: Saunders

 

 

Guidelines for

Medication Administration

 

         To protect the client from medication errors, nurses have traditionally used as a guideline the “five rights” of drug administration (see the accompanying display).

 

Right Drug

 

         Before administering any medication the nurse compares the medications listed on the MAR, other recording forms, or computer orders against the health care practitioner’s order. When administering a medication, the nurse should check the label written on the container against the MAR at least three times before giving the drug. The nurse should:

1. Check the label when removing the drug container from the client’s medication drawer.

2. Check the drug when removing it from the container.

3. Check the drug before returning it to the client’s medication drawer. Some medications come in a unit-dose prepackaged form. The nurse should check the medication a third time even though there would be no container to return to the drawer. This third check should be done at the bedside before opening the unit-dose medication. The nurse should give only medications that the nurse has prepared and checked. The nurse who administers the medication is the responsible party should an error occur. If a client questions a medication to be administered, the nurse should never ignore the question. Clients are active participants in their care and usually know when a medication is different from that usually taken. The nurse should withhold this medication until the order can be rechecked. Frequently, the medication order has changed, but the client question can stop an error before it occurs. If the client refuses a medication, it should be discarded rather than returned to the original container. Unit-dose medications that have not been opened can be saved.

 

 

 

 

Right Dose

 

         The unit-dose system was implemented to help decrease medication errors. However, there are times when  medications on hand are in a larger volume or strength thaeeded. Careful calculation is especially important when the health care practitioner orders a unit of measurement different from what is supplied by the pharmacy. The nurse must know how to reduce the risk of error by correctly calculating doses and having them doublechecked before administration. Policy in some agencies, for instance, mandates that two nurses check insulin dosages to ensure accuracy. After calculations have been completed, the nurse should prepare the medication using appropriate measurement devices such as graduated measuring cups, syringes, and droppers. To prepare scored or crushed medications, the nurse should make sure scored tablets are broken evenly. This practice will prevent overdosage or underdosage of a medication. If the medication has to be crushed with a mortar and pestle, the nurse should thoroughly cleanse the pestle after each use. Cleansing the pestle will avoid mixing of different medications and will prevent the client from receiving minute amounts of a medication that may cause serious adverse effects.

 

Right Client

 

The nurse should correctly identify the client by asking the client to state his or her full name and checking the client’s

 

 

Figure 29-3 Computerized Pharmacy Medication Administration Record

 

identification armband (Figure 29-4). Never identify a client solely by calling the person’s name because some clients may be confused and will answer to any name. Identification bracelets that become blurred or are missing for any reason should be replaced. The nurse needs to obtain a new identification band for the client. Verify the identification by asking the client to state his or her full name before placing the new band on the client’s arm.

 

Right Route

 

The route of the medication is specified in the written order. The nurse should consult the health care practitioner whenever a route is not identified in the prescription, when the route indicated differs from the recommended one, or when the nurse questions the choice of route prescribed. For example, the nurse should not substitute an oral medication for an  intramuscular medication simply because the oral medication is available and the intramuscular one is not.

 

 

 

 

 

Figure 29-4 Check a client’s identification band before administering

medication.

 

Injecting a medication designed to be administered orally can cause adverse reactions such as a sterile abscess at the injection site. Medications for parenteral injections should be prepared from medications designed for this purpose. Manufacturers of medications  label medications that can be used for parenteral injections as “for parenteral use only.”

 

 

Right Time

 

Medications are generally ordered on a schedule. Nurses are responsible for knowing why a medication is ordered on a certain schedule and for following that schedule as closely as possible. A drug should not be given more than a half-hour before or after the scheduled time (according to organizational policy) without first checking with the health care practitioner. To maintain the drug’s effect, the nurse has to give the medication in a timely manner. Some medications must be given at a certain time for proper therapeutic effect; for example, insulin should be given at a set time before meals. These types of drugs should be administered as ordered. See the Nursing Checklist for guidelines that ensure the safe administration of medications. In the home health and community care settings, such as a retirement home, the nurse has different responsibilities regarding drug safety (Figure 29-5). The nurse should promote drug safety measures that are appropriate to the environment and inherent risk factors (see the accompanying display).

 

Documentation of

Drug Administration

 

A critical element of drug administration is documentation. The standard is “if it was not documented it was not done.” Many drug errors can be avoided with appropriate documentation. The nurse responsible for administering the medication must initial the medication on the MAR near the time the drug is scheduled. Usually there is a space available for a full signature on the record. The nurse should document that a drug has been given after the client has taken the drug.

 

 

 

If the client refuses to take a medication once it has been prepared, the nurse must indicate that a dose was missed. In some hospitals, a circle is placed around the time the medication was scheduled to be given. The nurse should write in the record why the dose was missed and notify the health care practitioner. The client may have refused because the tablet was too large. The medication may be supplied as a liquid so an alternate form of the medication can be given; the nurse must request that the health care practitioner change the order to a liquid. Clients do have the right to refuse medications. However, if clients understand the actions of the medication, they may be willing to take the medication. Clients who are scheduled for various diagnostic tests or treatments at the time the medication is to be administered will need to have the medication times rescheduled.

 

 

 

 

 

Drug Supply and Storage

 

         Drugs are dispensed by the pharmacy to nursing units through various methods to accommodate the agency’s medication system. Once the pharmacy delivers the drugs to a nursing unit, the nurse is responsible for their safe storage. Scheduled drugs for each client are usually dispensed in a unit-dose form. Unit dose is a system of packaging and labeling each dose of medication by pharmacy, often to supply a 24-hour time period. The pharmacy usually delivers the drugs and stores the drugs in the designated area for each client. Unit-dose drugs are usually stored in a medication cart that contains individual drawers for each client’s medication supply or in the medication room in a separate, organized container for each client. The unit-dose system has made it easier for nurses to administer the correct dose, thereby reducing the number of medication errors. The nurse, usually at the beginning of each shift, checks the medications in each client’s drawer. Some medications carts are locked, and the nurse keeps the key. Medication drawers should be removed only one at a time from the cart when the nurse is preparing the medication for administration. The client’s drawer should never be left unattended on top of the cart. Drugs should not be removed from one client’s supply for administration to another client. Certain drugs are stock supplied (dispensed and labeled in large quantities) and stored in the medication room or other area on the nursing unit. Stock supplies are kept together in a secured area. Certain intravenous fluids and medications must be stored in the medication refrigerator to preserve the integrity of the drug. The Public Health Department and accrediting agencies mandate that only drugs can be stored in the medication refrigerator.

 

Narcotics and Controlled Substances

 

         Health care agencies have forms to record the supply on hand and the administration of narcotics and controlled substances in accord with federal regulations. These forms usually require the recording of the following information for each drug administered:

• Name of the client receiving the drug

• Amount of the drug used

• Time the drug was administered

• Name of the prescribing health care practitioner

• Name of the nurse administering the drug

         Nursing practice usually requires that nurses count the narcotics and controlled substances at specified intervals. For example, at the change of shifts, one nurse who is going off duty counts the drugs with a nurse coming on duty. Each drug used must be accounted for on the narcotic record. When the narcotic count does not check, the nurse must report the discrepancy immediately. Narcotics and controlled substances are kept in a doublelocked drawer, box, room, or medication-dispensing cart. The law requires these safety precautions in the use of narcotics and controlled substances to aid in the control of drug misuse. If for any reason a narcotic has to be discarded, a second person should act as a witness and that person should also sign the narcotic sheet.

 

Drug Abuse

 

         Federal, state, and local rules regulate the appropriate use of drugs. Despite these rules, some people use drugs for purposes other than their proper use, seriously jeopardizing their health. Misuse of drugs also creates problems for family  members and the community as a whole. “The American Medical Association and the World Health Organization have both recognized addiction as an illness, not a lack of willpower” (Dossey, Keegan, & Guzzetta, 2000, p. 514). Addiction is defined as a physiological or psychological dependence on a substance, such as alcohol or morphine, or a behavior such as eating, gambling, working, or engaging in sexual intercourse. The rest of this discussion focuses only on substance abuse.

Nursing practice requires the nurse to be knowledgeable about the addictive process in order to assess and care for clients with drug toxicity or overdose and withdrawal. Continual or periodic use of drugs may lead to dependence (reliance on or need to take a drug). The term chemical dependence is often used as a more inclusive term than drug dependence because it includes problems with all mind-altering substances that have the potential of creating dependence (Crosby & Bissell, 1989).

 

DRUG SAFETY CONSIDERATIONS

IN HOME HEALTH AND

COMMUNITY CARE SETTINGS

 

• Help the client remove outdated prescriptions and over-the-counter drugs from medication cabinets. The chemical composition may change over time, causing a different drug action. Over-the-counter drugs may interact with prescription drugs, either by decreasing or potentiating the effects of the prescription medication.

• Encourage the client or caregivers to maintain drug refills to decrease the risk of missing scheduled medications.

• Use a mechanism such as a paper clock, reminder calendar, or pill box to help the client or caregiver remember to take or administer prescribed medications as scheduled. Addiction implies more than a physical dependence alone, and it does not refer exclusively to illicit drugs. Illicit drugs are substances sold illegally, such as cocaine, PCP (angel dust), hallucinogenic agents (LSD and peyote), and cannabinoids (marijuana and hashish). There are two types of drug dependence that can occur separately or together:

• Physiological dependence: the biochemical changes in body tissues that occur when the tissue depends on a substance for normal functioning; cessation of the substance causes physical withdrawal symptoms.

• Psychological dependence: the emotional reliance on a substance to maintain a sense of well-being; the degree of psychological dependence can vary from a mild desire to an intense craving or compulsion for the substance. Although there are many types of addictions to various substances, alcohol addiction is the most prevalent one in the United States, afflicting at least 11 million people (Dossey et al., 2000). The nurse should be able to identify the characteristics of substance abuse (see the accompanying display) and work together with other health team members in planning the care for

clients experiencing the disorder.

 

 

 

         Nurses and other health care providers (physicians, dentists, and pharmacists) are at risk for substance abuse because of their access to drugs such as benzodiazepines (Valium, Librium), sedative hypnotics (Nembutal, Placidyl), amphetamines (Dexedrine, Benzedrine), and narcotics (meperidine, morphine). The actual incidence of chemical dependence among nurses and other health care professionals is difficult to document; however, it is estimated that 6% to 16% of registered nurses in the United States are chemically dependent (Crosby & Bissell, 1989). The difficulty of obtaining factual data for the number of chemically addicted nurses is often related to the reluctance of professionals to report one another.

         Although it may be uncomfortable to report an addicted colleague, nurses have a moral responsibility to report the situation to the appropriate authority. Nurses who are addicted may display suspicious behaviors such as insisting on carrying the narcotic keys and volunteering to administer all of the narcotics during the shift (see the accompanying display for other behavioral characteristics).

 

 

 

         In 1983, Florida was the first state to enact a “diversion” law as an alternative to disciplinary proceedings against substance abusers. Florida’s diversion program is called the Intervention Project for Nurses and has served as a model for other states to create similar programs such as impaired nurse programs. These programs provide support,  confidentiality, and stringent on-the-job monitoring and allow the nurse to maintain licensure as long as the nurse complies with the program. An impaired nurse program is a welcomed alternative for nurses with addictive behaviors and has increased the reporting of nurses with addiction problems. (Contact your state board of nursing office to inquire about alternative programs to disciplinary measures.) More recently, some hospitals have taken a proactive role in combating the problem of drug abuse among nurses with the use of a computer-controlled dispensing system (Figure 29-6). With this system, the likelihood of the nurse’s abusing narcotics is markedly decreased. The nurse enters a private security code. The system will provide the nurse with a printout of the medications given to the client and will charge the client. This dispensing system eliminates stock supplies of narcotics and controlled drugs, decreasing the nurse’s access to these drugs.

 

 

 

 

Figure 29-6 Computer-controlled Dispensing System

 

 

MEDICATION COMPLIANCE

 

         Medication compliance can be associated with the client’s understanding of why a medication was ordered and how a medication can decrease the likelihood of getting a disease or how it can lessen the effects of an existing disease. When clients do not consistently take their prescribed medications, or when they adjust the scheduling or dose of the medication, they are noncompliant. 

         There are several reasons why clients choose not to take ordered medications. If a hypertensive client is asymptomatic (without distress), it may be difficult for the client to understand the need to take prescribed medications. If medications are taken, the dose may be altered at the discretion of the client. Medications are costly, and the client may be on a fixed income or unemployed. If the medication does not provide prompt relief, the client may consider the medication useless and discontinue it. The medication may be discontinued if the client experiences undesirable side effects, such as dizziness, impotence, or weight gain. Compliance can be enhanced if the client is given information on the medication to take home when discharged from the hospital. If the client is elderly, largetype print or illustrations should be used. Caregivers should be included when educating the client. Scheduling the medications around certain activities of daily living may serve as a reminder to the client that the medication must be taken. Providing the client with a telephone number and a name of a nurse to call if questions arise can ensure compliance. The nurse in the community has an opportunity to see how medications are arranged in the client’s home. Outdated medications must be discarded. After consulting with the client and caregiver, the nurse can make suggestions that may improve compliance. Nurses have to remember that many elderly clients take a multitude of drugs. Some drugs actually cancel each other out when taken together, thus eliminating the therapeutic response. A client taking BuSpar and digoxin may experience digoxin toxicity. BuSpar may displace the serum binding of digoxin and increase the toxic levels of that drug (Shannon & Wilson, 1995). Nurses must sort through the medications with the client and report back to the health care practitioner the drugs taken in addition to those ordered by that health care practitioner.

 

LEGAL ASPECTS

OF ADMINISTERING

MEDICATIONS

         Clients are awarded settlements in malpractice suits wheurses are negligent in their practice. Negligence exists any time the nurse fails to do something that a reasonable nurse would do under similar circumstances or does something that a reasonable nurse would not do. Malpractice is any professional misconduct or unreasonable lack of skill in professional duties. See Chapter 23 for related information on legal issues.

Medication Errors

 

         Nurses have learned the “five rights” as a guideline to safe administration of medications. If the nurse gives the wrong medicine to the wrong person, an error has been made. If the nurse has the right medicine but wrong dose or wrong route, a medication error has been made. If the nurse gives the medication at the wrong time, an error has been made. Nurses must inform the health care practitioner of the error made. If an antidote must be given, the health care practitioner needs accurate information to make appropriate care decisions. Medication errors must be reported in a timely manner. Knowing the actions and the side effects of drugs will help the nurse assess the client’s response and health status. Incident reports are required in some agencies to document medication errors. A report of a medication error must include the name of the medication, the dose given, the route, the time the medication was administered, the specific error that occurred, the time the health care practitioner was contacted about the error, and what countermeasures were taken. Sometimes nurses discover errors made by other nurses. These must also be documented.

Questioning the Medication Order 

         The nurse is responsible and held accountable for questioning any medication order if, in the nurse’s judg- ment,  he order is unclear or in error. The nature of the  error may be in any part of the drug order, and the nurse should seek clarification from the health care practitioner. A drug error has serious legal implications if the nurse involved could have been expected, on the basis of knowledge and experience, to have noted the error. If the health care practitioner disregards the nurse’s query, another line of authority must be pursued by the nurse to prevent a drug error. The medication in question

should not be administered until the order has been clarified. The nurse should withhold any drug when the client’s health may be jeopardized. Notify the health care practitioner of the need to withhold the medication and the reason withholding it is necessary. Document the reason for withholding the drug (such as withholding a dose of an antihypertensive medication due for a patient who is currently experiencing hypotension) on the medication administration record (MAR) and the nurse’s notes. When the nurse is not able to read or understand the order, the prescriber should be contacted for clarification.

The nurse should not guess what the person who wrote the order is trying to communicate; the only safe nursing action is to validate the order with the health care practitioner.

ASSESSMENT

         Drug administration is based on assessment data obtained by reviewing the client’s medical history, eliciting a drug

history, performing a physical examination, and obtaining and interpreting relevant laboratory results. Assessment is an ongoing process and requires the knowledge, skills, and abilities of a licensed professional.

Medical History

         The client’s medical history is obtained by the nurse when conducting the interview assessment and by reviewing the client’s medical record. The nurse should identify all chronic diseases and disorders and correlate these data with the drugs prescribed by the health care practitioner. Because the client may have more than one health care practitioner, the admitting health care practitioner might not be aware of all the drugs the client is taking, including over-the-counter medications. It is the nurse’s responsibility to gather this information and document it on the client’s chart. Preexisting conditions such as liver and kidney dysfunction may require drug alteration because they prolong drug action, thereby increasing the potential for toxicity. The nurse needs to elicit this type of information during the medical history so that these clients can be closely monitored for signs of adverse reactions to drugs.

 

Drug History

         A drug history is obtained on admission to a health care facility. The drug history should contain specific questions

about the client’s background: allergies, prescription and over-the-counter drugs, medical history, biographical data, lifestyle and beliefs, and sensory and cognitive status. See Chapter 16 for a complete discussion of taking a health history. If the client is unable to answer the questions, the nurse should contact a family member to obtain the data. Drug history data are used by nurses in determining the client’s plan of care and learning needs.

 

Allergies

 

         The nurse should inquire about all food and drug allergies. If the client has had an allergic reaction to a drug, the nurse should have the client describe the details of the reaction: name of the drug; dosage, route, and number of times the drug was taken before the reaction; onset of the reaction; and manifestations of the reaction. The nurse should question the client about possible contributing factors to the allergic reaction, such as concurrent use of stimulants (tobacco, alcohol, or illegal drugs) or significant changes in nutritional status. The nurse should also ask about allergies to foods because drugs may contain the same elements or nutrients that cause allergic reactions to some foods. For example, clients who are allergic to shellfish may also experience a reaction to drugs containing iodine. Vaccines are commonly derived from chick embryos and would be contraindicated in clients with allergies to eggs. Allergies to food and drugs, including over-thecounter drugs, should be noted in the client’s record, in the admissioote, on the medication administration record, and on the history and physical examination forms. The pharmacy should be notified of any drug or food allergies. In hospitals, clients wear allergy alert bands that list all medications to which the person is allergic. Nurses in all settings should discuss the use of medical alert bracelets by clients with allergies. These bracelets would inform health care providers of allergies should the persoot be able to speak for himself or herself.

 

 

THINK ABOUT IT

 

Medication Error

While monitoring a client who has an order for SoluCortef (anti-inflammatory drug) intravenously, you notice that Solu-Medrol (anti-inflammatory drug) is in the client’s room. You recheck the order to make sure that the original order was for Solu-Cortef and that the order was not changed. What should your next action be? How do you feel about the nurse who made the medication error but did not recognize it?

 

Prescription Drugs

 

         The nurse should have the client identify all current prescription drugs and describe:

• Why the drug was prescribed and by whom

• The drug’s dosage, route, and frequency

• The client’s knowledge of the drug’s action: side and adverse effects, when to notify the health care practitioner, and special administration considerations such as with or without foods If the client is receiving any drug that requires monitoring before administration such as insulin (antidiabetic hormone), the nurse needs to make sure the client is checking blood sugar and that the results are withiormal limits.

 

Over-the-Counter Drugs

         Clients usually have to be questioned separately about nonprescription drugs because they often fail to identify these drugs when asked to list all the medications they take routinely. For example, the nurse must determine if the client takes aspirin, antacids, or laxatives routinely. The client should describe the dosage, route, and frequency of these drugs. Because many drugs are available in topical form, the nurse should also inquire about the use of creams, ointments, patches, or sprays. Clients admitted to inpatient facilities should be asked if they have any over-the-counter drugs with them. The nurse should explain to the client in a sensitive manner why these questions are necessary in order to allay any anxieties that might arise from this nature of questioning. Depending on the dosage and frequency, nonprescription drugs may have a profound effect on the client’s treatment.

 

Biographical Data

         The client’s biographical data, including age, education, occupation, and insurance coverage, may influence the nursing care plan and teaching plan. These data are also used by the nurse when helping a client develop a drug regimen that complements the client’s daily routine.

 

Lifestyle and Beliefs

 

         The client’s lifestyle and beliefs affect attitudes toward health, use of the health care system, and daily activity patterns. These factors often determine the client’s dietary habits and nontherapeutic use of drugs such as tobacco, alcohol, and illegal drugs.

 

Sensory and Cognitive Status

 

         The nurse should assess for and inquire about sensory deficits such as vision or hearing impairments, weakness or paralysis, or loss of sensation in one or more extremities. These deficits may impair a client’s ability to comply with a prescribed drug plan, administer a subcutaneous injection, break a scored tablet, or open a medication container. The nurse should assess the client’s cognitive abilities throughout the drug history interview by noting whether the client is alert and oriented and interacts appropriately. Clients who are not able to express their thoughts coherently or who exhibit impaired memory function will require special consideration by the nurse when planning the client’s care and teaching plan. See Chapter 36 for a complete discussion of sensory and cognitive impairments.

 

 

Physical Examination

         The nurse conducts a physical assessment to identify those body systems that may be affected by a particular drug the client is currently taking or will be taking. The nurse assesses the client’s condition before administering any drug to establish the client’s baseline, or normal, health status. For example, the nurse assesses the client’s apical pulse before administering Lanoxin (inotropic) so that the heart rate after receiving the drug can be compared with the baseline measurement.

 

Diagnostic and Laboratory Data

         Common laboratory values, such as electrolytes, blood urea nitrogen, creatinine, glucose, complete blood count, and a white blood cell count, are usually monitored over a period of time to identify trends and to measure the body’s response to medications. Laboratory results are evaluated on the basis of the client’s clinical condition, physical assessment, and drug therapies. See Chapter 28 for a complete discussion of laboratory testing.

 

NURSING DIAGNOSIS

         The nurse analyzes the assessment data to determine the client’s ability to self-administer medications and to identify any potential or actual drug-related problems. Once the nurse identifies the actual or potential problems, relevant nursing diagnoses can be formulated. The commoursing diagnoses specifically related to medication administration are:

• Deficient Knowledge

• Ineffective Therapeutic Regimen Management

• Ineffective Health Maintenance

• Impaired Physical Mobility

• Disturbed Sensory Perception

• Impaired Swallowing

The addictive client may have a different set of nursing diagnoses, such as:

• Imbalanced Nutrition

• Impaired Verbal Communication

• Interrupted Family Processes

• Impaired Social Interaction

• Social Isolation

• Spiritual Distress

• Readiness for Enhanced Spiritual Well-Being

• Ineffective Coping

Selecting the most appropriate nursing diagnosis will identify the client’s teaching needs.

 

PLANNING

         Nurses need to carefully plaursing care activities to ensure safe administration of medications. Reviewing scheduled diagnostic tests, laboratory results, and the overall plan of care helps to ensure that clients receive medications at the appropriate time and that medications that should not be given are withheld until their administration can be clarified with the health care practitioner. For example, digoxin might be withheld if the lab test indicates an above-normal level. Medication administration is a good time for nurses to incorporate client teaching. Adequate planning provides for questions

and discussion by the client and demonstration of skills learned (as in self-administration of insulin injections). Planning ahead ensures that enough time is allocated for the client to accomplish all the desired tasks in a timely manner.

 

OUTCOME IDENTIFICATION

 

         The nurse develops goals and plans the care on the basis of the nursing diagnosis. Inherent in the plan of care is client teaching based on medications prescribed. Nursing interventions are identified and incorporated into the plan of care to promote the attainment of goals and to assist the client in achieving expected outcomes. For example, the client with deficient knowledge related to a newly prescribed drug, insulin, may have the following expected outcomes:

• Client will correctly state the actions of insulin in the body before self-administering insulin.

• Client will prepare the correct dose of insulin in a syringe three times before discharge.

• Client will state the reasons for rotating the injection sites and demonstrate by self-administering insulin to three different sites before dicharge.

• Client will correctly identify the onset of action, peak plasma level, and half-life of the insulin preparation prescribed before self-administering insulin.

• Client will correctly perform glucometer testing to ensure a normal range of blood sugar before administrating the insulin injection.

• Client will correctly describe the signs of hyperglycemia and hypoglycemia and the appropriate actions to take before discharge.

         Most clients admitted to a hospital or a long-term care facility have one or more nursing diagnoses related to alterations that precipitated the admission. Inherent in their nursing care plans are expected outcomes related to medication administration. For example, the nursing diagnosis Ineffective breathing pattern related to decreased energy may have as a client outcome, demonstrates correct use of a metered-dose inhaler. See the sample Nursing Care Plan at the end of this chapter for additional examples of client expected outcomes related to medication administration.

 

IMPLEMENTATION

         The primary nursing interventions related to medication management are assessment, administration, and teaching. The nurse should use the time spent with the client during medication administration to assess the client’s knowledge and response to the drug’s action. The administration of medication requires the implementation of safety guidelines, following the five rights. Medications are administered in accordance with set procedures based on the prescribed route. This section presents procedures and guidelines for medication administration by the following routes: oral, including sublingual, buccal, and enteral; parenteral; site-specific topical applications; and inhalation. Once the teaching plan has been developed, the nurse should initiate discharge teaching of drug therapy. Assessment data, especially the client’s history, help the nurse in determining who should be included in the teaching session. For example, an elderly client living alone is physically capable of self-administering but may have short-term memory loss. In this situation the nurse should obtain the client’s permission to include a family member, neighbor, or friend in the teaching session. Drug teaching usually occurs in two phases. The first phase involves a formal teaching session. The nurse explains the drug’s action, route, side and adverse effects, and the specific signs of a drug reaction that require physiciaotification. Clients ofteeed assistance in developing a drug schedule that promotes compliance and complements their lifestyle. Self-administration may require the nurse to teach the client specific procedural techniques, such as subcutaneous injection. The second phase of client teaching is ongoing, occurring whenever the nurse administers a drug. The nurse should assess and reinforce the client’s knowledge of drugs at each interaction. If the client is being taught self-administration, the drug teaching plan should identify the dates for teaching, and expected outcomes should identify a date for client achievement of targeted goals